How to Maintain a Legally-sound Health Record

Record keeping is an important tool in any organisation, but the way it is been handled in many health organizations needs to be re-addressed. There is a need to look into things that need improvement especially if it's getting to the point of affecting the major aim of all health establishments which is; 'saving lives'. I have not written this article to point accusing fingers to health workers on the subject matter but has find it neccessary to open your eyes to the concerns that are becoming the weakness of health organizations.

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Time will not permit me to give in details, my experiences on the subject matter, but will try to pen down facts which will lead to my suggestions and advice as to my knowledge. As to my references in this letter, i am directing the responsibility to each head of private organizations such as medical directors/manager/director etc as it is called in different establishement, because you should be responsible for the upkeep of all the departments of your organization. Please sir/ma, kindly treat this case with optimum urgency

I was priviledge to be part of the health team that did a state evaluation of the health organizations' records inorder to collate some health data of the state. To my surprise, About 78% of the private organizations such as hospitals/clinics, pharmacies, laboratories, physiotherapy centres, dental clinics, eye clinics etc had poor legally sound health records. Infact, some of these health organizations could not present their patient file records nor have a central logbook that has the compiled records.

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Sir/Ma, the sight of this menace caught me unaware because i could not believe what i saw in your health organizations. I will not be going deep on this issue as i understand how confidential this matter is. But i still deem it fit to raise this alarm so that if it's that you as the head of your own health organization was too busy to attend to examining this department, then i believe you should deem it fit to appoint an expert to monitor your health records.

Health records assists in protecting the legal interest of the patient and the health care providers. Health record is therefore a legal document because the organization, by law, must have a health record. The health record by definition must meet all statutory, regulatory and professional requirements to be a valid health record for clinical purposes as well for business purpose. If the record does not qualify as health record, it becomes hearsay, not a bonafide record and its integrity for any all uses become suspect

Sir/ma there is a lot to talk about on this issue, but i just want to point out salient point that could be very helpful in corecting some of this menace. Infact, i am no more concentrating this letter on the need to make necassary amends to prevent likely sanctions from the Government, but also passionately looking forward for the records to meet the legal health standard. Therefore, here are the basic principles that must be met for the health records to be deemed admissible as evidence in court. The record must have been:

●Documented in the normal course of business (following normal routines)
●Kept in the regular course of business
●Made at or near the time of the matter recorded
●Made by a person within the business with knowledge of the acts, events, conditions, opinions, or diagnoses appearing in it.

Therefore, regardless of its format –paper, hybrid, or fully electronic, - the health record must meet the following legal and business record for requirements for the organization:
●Maintain a medical record for each patient
●Properly field and retained to ensure retrieval
●The health record must be accessible
●The health record system must ensure that medical record entries are not lost, stolen, destroyed, altered, or reproduced in an authorized manner.
●Locations where health records are stored or maintained must ensure the integrity, security and protection of the records.

It is also essential to note that that all entries in the medical records must be timed, dated, and authenticated; and a method established to identify the author. Entries should be made as soon as possible after an event or observation is made. The use of specific anguage should be encouraged whiule vague or generalized language avoided. Examples of generalization and vague words include patient doing well, appears to be, confused, anxious, status quo, stable, as usual.

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Healthcare organizations should set a standard for acceptable abbreviation to be used in the health record and develop an organization specific abbreviation list. Organizations shold define the level of record documentation expected of their practitioners based on the practitioners’ licensure, certification, and professional experience. Maintain a legally sound health record covers a huge territory from the content of the heatlh record and how entries are recorded to the functionality in the system to access, and security. While the electronic age brings new variables to an old and complex problem, the foundation remain the same: health, records must be maintained in a manner that follows applicable regulations, accreditation standards professional practice standards, and legal standards.

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Conclusion

Health information Management professionals must play a critical role in the transition from paper to electronic records and must partner with clinical, legal and information techjnologist to adequately address the legal business issues for the heatlh record. Remember to document it because if you have not document it, you did not do it!!!.

I am grateful for taking your time to read through this article and I hope to see significant improvement during the next round of health records evaluations in the state. Thank you.

REFERENCES

Importance of vital records and statistics

Health data

Everything you need to know about electronic health records

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