Management of Medical Records

From U of M Internal Medicine Wiki
Policies
Policy: Management of Medical Records
Policy Nr: Sec 03 - 05
Target Review Date: 2017-12-31
Main Stakeholder:

Background

Most Internal Medicine Ambulatory Care Clinics at the Health Sciences Centre use the Health Sciences Medical Record. These charts may be secured in a physician’s office after each clinic for patient call reasons. Physicians and staff often retain charts for periods longer than the approved retention time resulting in delays in retrieving and accessing files in a timely and efficient manner.


Policy

  1. It is the HSC’s policy that the medical record may be retained following a clinic visit to facilitate documentation or dictation but shall be returned to the Medical Information Department no later than 10 calendar days following the clinic visit.
  2. When the medical record is required by the physician for a longer period of time he/she will advise the Medical Information Department and provide the chart number, the location (room number) where the medical record will be held and the telephone number of an individual who may be called to obtain the medical record to return it to the Medical Information Department.
  3. Support staff will return all medical records to the Medical Information Department on the 11th calendar day following the clinic. He/she will prepare a list of charts which will include chart number, and patient name. The list will be reviewed with the physicians.Interro-01.gif What does that do? Will they be reviewed before or after returning the chart? Ttenbergen (talk) 12:42, 29 May 2017 (CDT)
  4. In all cases, the HSC medical record will be returned to the Medical Information Department no later than 21 calendar days following the clinic.

Interro-01.gif Is this only at HSC? Is it actually an HSC policy to which we could link instead? What do other sites do?


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