Free Essay

Hybrid Records

In: Computers and Technology

Submitted By bluenavy76
Words 1257
Pages 6
Angela Cicchetti
HIM 4/28/14
The storage and destruction of hybrid charts
Angela Cicchetti
HIM 4/28/14
The storage and destruction of hybrid charts

Hybrid Records

The use of a hybrid chart can be beneficial and yet at times it can be a liability if it is not looked after and stored correctly and efficiently. Hybrid charts are used in paper and computer format. The hybrid chart can be very useful and it also holds potential for liability if not stored correctly. The paper hybrid chart can be stored in a few different ways but it is up to the office manager to choose which method is the most efficient, effective and holds the less chances of liability for the healthcare facility. There are three processes that are implemented when storing a hybrid chart. These processes are creation and identification, storage and retrieval, and retention and disposition. As long as these three processes are integrated in the storage and usage of hybrid charts then the charts will be effective and protected from liability at the same time. The best charting system for the paper part of the hybrid chart depends on how big the organization and facility are that are filing and storing these paper charts. Smaller healthcare facilities use an alphabetical or numerical charting system to find the paper charts fast and efficiently. The larger healthcare facilities use more advanced chart filing systems such as a unit number system where the patient receives one number that is linked to only that patient and is used over and over throughout their visits to the physician’s office. The other factors that present themselves when choosing a record identification system are the core processes of the facility and the filing system that is available. The filing system will be chosen by HIM professionals who will be the sole people who are in charge of keeping the charts safely stored and away from legal obligations.
There are many more strengths than weaknesses when pertaining to a hybrid chart. The key advantage of using a hybrid chart is the hybrid charts sustain the format of the paper based record after the patient has been released and discharged from the healthcare facility. Healthcare facilities that choose to scan the documented paperwork into the chart of the hybrid record delivers benefits of the electronic health record. The benefits of the hybrid record are, more rapid and simultaneous access by providers, less manpower is needed for filing paperwork, purging the records and looking for missing paper charts, there is less space required to archive compared to having only paper based charts, physicians have the ability to remotely access the patient’s hybrid record for charting completion and hybrid charts reduces that of incomplete and delinquent health records since physicians don’t have to wait until the record is available and or the physician does not have to check in with the HIM department throughout the day to complete their charting in the patient’s records.(La Tour 2013) The weak points of hybrid charts are that the scanned hybrid records cannot be searched for content and are not as advanced electronically. The images that are scanned into the hybrid charts are compromised and are not separate fields that can be searched in the hybrid format. (LaTour, 2013).
The two main legal concerns or issues that arise with the use of hybrid charts are that the information in the electronic health record provides evidence in a lawsuit that the quality of patient care was met and provided, the use of the electronic medical record is not accessed by unauthorized users, and that there is not careless handling of the patient information within the patients EHR. There is a debate that addresses whether or not the EHR can be admitted as evidence in the court of law amongst the HIM professionals and state regulators. This touches base with the first concerned mentioned. The second issue mentioned concentrates on how to keep the EHR environment safe and secure legally from theft and hackers. There are also some legal liabilities and issues with whether or not the EHR will be admissible in the court of law. (LaTour, 2013) The “Willow Bend Record Policy” does support the information found on storage, and destruction of medical paper and electronic charts on the Washington State wac, Medicare Conditions and Participation, and HIPPA website recommendations. When looking up the rules and regulations on the retention, storage and destruction of hybrid charts on the Washington State wac, Medicare Condition and Participation, and HIMMA web pages, the information found all stated the same recommendations about storing and the destruction of hybrid medical charts. The record schedule for all three sites are as follows:
Retention and Destruction of Health Information (Updated 2011)
Appendix C: AHIMA's Recommended Retention Standards Health Information | Recommended Retention Period | Diagnostic images (such as x-ray film) (adults) | 5 years | Diagnostic images (such as x-ray film) (minors) | 5 years after the age of majority | Disease index | 10 years | Fetal heart monitor records | 10 years after the age of majority | Master patient/person index | Permanently | Operative index | 10 years | Patient health/medical records (adults) | 10 years after the most recent encounter | Patient health/medical records (minors) | Age of majority plus statute of limitations | Physician index | 10 years | Register of births | Permanently | Register of deaths | Permanently | Register of surgical procedures | Permanently |
(AHIMA 2013) The information in the chart above was also stated on the Medicare webpage that the regulations and recommendations of chart storage and destruction should follow the state and facility protocols in how to manage the chart storage and destruction of charts. The following information was found on how to destruct the patient chart and it follows what the Willow Bend Record Policy: In the absence of any state law to the contrary, organizations must ensure paper and electronic records are destroyed with a method that provides for no possibility of reconstruction of information.
Examples of destruction methods are provided below: * Paper record methods of destruction include burning, shredding, pulping, and pulverizing. * Microfilm or microfiche methods of destruction include recycling and pulverizing. * Laser discs used in write once-read many document-imaging applications are destroyed by pulverizing. * Computerized data are destroyed by magnetic degaussing. * DVDs are destroyed by shredding or cutting. * Magnetic tapes are destroyed by demagnetizing. (AHIMA 2008)
The storage and destruction of charts is a serious matter that if not done correctly could potentially break HIPPA laws and the confidentiality of patient information could be breeched. This has potential to cause legal matters. It is very important to ensure that when storing and destructing patient charts that it is done by following state, medicare and HIPPA guidelines to protect the privacy of the patients. Following the recommendations of all three areas should shield and protect healthcare facilities from potential lawsuits. Knowing how to store and destroy hybrid charts is crucial to maintaining patient privacy and creating protection against potential lawsuits against healthcare facilities.

References

AHIMA. "Retention and Destruction of Health Information. Appendix C: AHIMA's Recommended Retention Standards." ( August 2013) Retrieved from: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_049252.hcsp?dDocName=bok1_049252
AHIMA. "Enterprise Content and Record Management for Healthcare." Journal of AHIMA 79, no. 10 (2008): 91–98. Retrieved from: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_049252.hcsp?dDocName=bok1_049252
Kathleen LaTour, Shirley Eichenwald Maki, and Pamela K. Oachs. Health Information Management: Concepts, Principles, and Practice. AHIMA Press, Bookshelf. (2013) Retrieved from: (https://online.vitalsource.com/#/books/978-1-58426-377-7/pages/79398826

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