Medical Record Division Policies and Procedures
1. Purpose
The purpose of this document is to establish and communicate policies and procedures for the
Medical Record Division of [Hospital Name]. These policies are designed to ensure the accurate,
confidential, and secure management of patient information in compliance with all relevant laws and
regulations.
2. Scope
This policy applies to all personnel within the Medical Record Division and any other hospital staff
involved in the creation, maintenance, access, and release of medical records.
3. Compliance with Laws and Regulations
All activities within the Medical Record Division must comply with applicable laws and regulations,
including but not limited to the Health Insurance Portability and Accountability Act (HIPAA) and
[relevant local regulations].
4. Access and Release of Medical Records
4.1 Authorized Access
Access to medical records is restricted to authorized personnel only. Staff members must undergo
appropriate training and receive proper authorization before accessing patient records.
4.2 Release of Medical Records
Patient records will only be released to individuals with proper authorization, including the patient,
legal representatives, and other entities as required by law. Requests for records must be
documented and validated before release.
5. Patient Privacy
5.1 Confidentiality
All personnel must maintain the confidentiality of patient information. Discussions about patient
cases should be conducted in private areas to protect patient privacy.
5.2 Disclosure Warning
Staff members should be aware of the potential consequences of unauthorized disclosure of patient
information, including legal and disciplinary actions.
6. Record Retention and Destruction
6.1 Retention Period
Medical records will be retained for a period in accordance with legal requirements and hospital
policies.
6.2 Destruction Procedures
Procedures for the secure and permanent destruction of medical records must be followed to
prevent unauthorized access.
7. Recordkeeping Standards
7.1 Documentation Standards
All medical records must adhere to established documentation standards to ensure accuracy and
completeness.
7.2 Timeliness
Records should be completed in a timely manner to support patient care and regulatory compliance.
8. Electronic Health Records (EHR)
8.1 Access Controls
Access to electronic health records (EHR) is controlled through secure user authentication and access
management protocols.
8.2 Data Encryption
EHR data is encrypted to protect patient information from unauthorized access.
9. Quality Assurance and Audits
Regular quality assurance checks and audits will be conducted to identify and rectify errors or
discrepancies in medical records.
10. Training and Education
All personnel involved in medical records management must undergo training on privacy regulations,
security protocols, and recordkeeping standards.
11. Security Measures
11.1 Physical Security
Physical access to areas where medical records are stored is restricted to authorized personnel.
11.2 Cybersecurity
Appropriate measures, including firewalls and antivirus software, will be implemented to protect
electronic medical records from cyber threats.
12. Incident Reporting and Response
12.1 Reporting
Any incidents involving unauthorized access, disclosure, or loss of medical records must be promptly
reported to [Designated Authority].
12.2 Response
A response plan will be enacted to address and mitigate the impact of incidents involving medical
record breaches.
13. Communication and Collaboration
Effective communication and collaboration will be maintained with other hospital departments to
ensure coordinated patient care.
14. Patient Rights
14.1 Access
Patients have the right to access their medical records upon request.
14.2 Amendments
Patients may request amendments to their records if inaccuracies are identified.
14.3 Copies
Patients may request copies of their medical records in accordance with hospital policies.
15. Revision and Review
These policies will be reviewed annually and revised as necessary to ensure compliance with
changing laws and industry standards.
