Functions of the Medical Records Committee
The medical records committee is a crucial body in a healthcare organization. Responsibilities of the medical records committee include formulation and enforcement of policies and procedures for the management of medical records. However, these roles are virtually ineffective if they are not supplemented with risk management, a critical practice in the management of medical records. Therefore, proactive efforts to reduce the chances of risks to medical records, such as breach of privacy and security or damage, are also within the docket of this committee. Risk management measures include risk assessment, continuing education, maintenance of incident data and statistics, and liaison.
Functions of the Medical Records Committee
The medical records committee is tasked with formulating policies and developing procedures pertaining to the management of medical records in a healthcare organization. Various service delivery needs may require medical records to be released from storage areas. The committee defines the policies that dictate the circumstances under which such records can be retrieved and the procedure for retrieval (Pozgar, 2018). The committee also formulates policies that stipulate how these records are stored, including policies on designated storage units for specific types of records (Pozgar, 2018). Policies to enhance security, such as a badge or keypad access for document storage units, are also devised by this committee.
Similarly, the committee determines and designs the format for completing medical
records by clinicians and various healthcare providers within an organization. Designing templates for various kinds of medical records, including clinician case notes for different patient groups, outpatient and inpatient admission log format, drug prescription forms and records, and care plans, is the responsibility of this committee (Pozgar, 2018). This enhances the accuracy and uniformity of the personal health information of patients. Additionally, it encourages the complete entry of all relevant and essential client information in accordance with standards of practice.
Finally, the committee ensures that the various healthcare providers in the healthcare organization who handle and complete medical records are compliant with the established documentation policies and procedures. The committee ascertains that the personal medical record of each patient is entered in a timely manner, and reflects their illness, the results of any investigations provided, and details of the type(s) of therapy provided (Li, 2015). The committee takes or recommends disciplinary action for breaches of documentation standards such as late entries.
Risk Management Facilitation
Risk assessment involves the identification of potential hazards and risk factors in the medical records system of the healthcare organization and using this information to institute security measures (Khumalo, 2017). Hazards and risk factors, including data entry errors, unauthorized access to patient’s personal health information, poor handling of records such as leaving files unattended, and potential technical failures, can be identified early through risk evaluation. This then allows measures to avert the risks from occurring, such as the institution of information verification procedures to minimize data entry errors (Khumalo, 2017). Risk assessment also allows mitigation measures to be instituted for potential risks such as the installation of fire extinguishers near records storage areas.
Aside from risk assessment, risk management can be facilitated through the provision of continuous education and training to the healthcare staff of an organization on the management of medical records. Staff training is critical in enhancing compliance with stipulated documentation policies and procedures (Roehrs, 2017). All healthcare workers in the organization who are authorized to handle various medical records can be continually trained on various aspects of medical record management. These aspects include authentication procedures, procedures for retrieval of records, the necessary scope of competencies or authorization for accessing specific records, and storage locations and requirements for specific records.
The other approach to risk management is the maintenance of data and statistics on incidences related to medical records (Sheikh, Sood, & Bates, 2015). Incidents such as breaches of standards of documentation, data leaks, and loss of medical records should be constantly recorded as soon as they occur, and the data should be made available to the medical records committee. The data can then be used by the committee to plan and implement risk management measures (Sheikh et al., 2015). Statistics help the medical records committee to identify the high-priority areas for which to allocate more risk management and mitigation resources and efforts.
Biblical Worldview
As the committee that is charged with the role of safeguarding the personal health information of clients of a healthcare organization, the medical records committee has a stewardship obligation to these clients. According to the Bible, when an individual is given a responsibility, it is their duty to devotedly discharge it. Those who have been given a trust must prove faithful (1 Corinthians 4:2, New International Version). As such, when formulating policies and procedures for the management of medical records, the medical records committee should execute this task as stewards who have been entrusted with a duty to the organization’s clients. The committee ought to demonstrate in all respects, “ to be a model of good works, and…show integrity, dignity…” (Titus 2:7, English Standard Version) Faithful performance of these roles will ensure the committee upholds principles that truly serve the interests of clients, a responsibility the healthcare organization has trusted it with.
Similarly, it is a biblical duty of the medical records committee to uphold patient privacy and confidentiality. Being the entity that is responsible for the management of medical records in the organization, it is responsible for the privacy and confidentiality of the sensitive personal health information of clients. Personal health information includes information that may be damaging to the reputation and psychological well-being of an individual. No one would wish to endure the stigma and psychological anguish that results from the disclosure of their private and confidential information. According to the Bible, “Whatever you wish that others would do to you, do also to them”. Members of the committee should, therefore, put themselves in the shoes of clients while formulating these procedures and policies. They should ensure that the policies they formulate to safeguard medical records adequately guarantee their privacy if they are clients of the organization.
The medical records committee is a crucial committee in any healthcare organization, thanks to the sensitive nature of personal health information. Besides formulating standards for the storage, retrieval, and security of medical records, the committee also develops the format for various medical records and documents. Additionally, it enforces compliance with established standards by executing or recommending disciplinary action for any contraventions. Furthermore, the committee should engage in risk management, an effort that can be facilitated through proactive risk assessment, staff training and education, and maintenance of data and statistics of incidences related to medical records. It is the biblical duty of the committee and its members to faithfully safeguard medical records and uphold patient privacy and confidentiality.
References
Khumalo, B. N. (2017). Records Risk Assessment at a Hospital in Zimbabwe. Library Philosophy and Practice.
Li, J. (2015). Ensuring privacy in a personal health record system. Computer, 24-31.
Pozgar. (2018). Legal Aspects of Health Care Administration. Jones & Bartlett Learning.
Roehrs, A. (2017). Personal health records: a systematic literature review. Journal of medical Internet research.
Sheikh, A., Sood, H. S., & Bates, D. W. (2015). Leveraging health information technology to achieve the “triple aim” of healthcare reform. Journal of the American Medical Informatics Association, 849-856.
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In this session, we will examine healthcare’s leadership and governance structure. Healthcare organizations are corporations with certain requirements depending on whether they are for-profit or non-profit. A structure is required and useful to address all the issues in this type of company. The executive team is responsible for all the various professions in the organization, requiring executives to be competent in their own areas of responsibility.
Functions of the Medical Records Committee
We’ll also be touching on crime in healthcare and looking at who should be taking responsibility for what. Although you may not be the attorney involved and accountable for a trial preparation, investigation, or legal defense, you will be involved in supporting the entire process. This includes your understanding of law, criminal or civil issues, preparation, language, and what constitutes criminal behavior. In addition, you may be responsible for supporting the legal defense of such cases and what those defenses might entail.