A Guide to Medical Records Management

With General Data Protection Regulations now in place, there is even more importance placed on the proper management of records that may contain sensitive and personal information.

Within the medical and healthcare industry, institutions such as doctor’s surgeries and hospitals can often become overloaded with substantial amounts of data that contain medical records, names and addresses of patients.

How can you keep your patient’s data safe?

Protecting data in the healthcare industry isn’t straight-forward and businesses must ensure that this data is secure and inaccessible to external threats. GDPR compliance is critical in this industry and noncompliance can have severe impacts to businesses, such as hefty penalties, fines and a tarnished reputation.

Patient information may be accessed by different people; however, it is important to ensure that only the people with access can view patient data and medical histories. Anyone viewing data who doesn’t have authority to do so is a breach of GDPR protocol and could result in data leaks if data is mishandled or misused.

To keep patients’ data safe and secure at all times, here are our best practices:

  • Educate staff on the importance of data security and the impact of data leaks
  • Allow data access to authorised personnel only
  • Log and monitor data access, also review this frequently
  • Encrypt data on all devices, including mobile devices that may be used remotely
  • Use off site document storageto ensure data is secure and out the way of unauthorised staff
  • Create digital copies of documentsfor quick and easy access by those who are authorised
  • Dispose of documents by shredding, this makes recreation virtually impossible
  • When reviewing or updating data access policies, notify and retrain staff so they are aware of new changes

Staff education is the most important factor to consider when keeping patient data safe and secure. Human error can often happen, but this can have a disastrous impact. Ensuring that staff are aware of GDPR policies, what to do and the risks of data landing in the wrong hands will help staff make smart decisions and use appropriate caution.

Alongside this, only allowing data access to the appropriate staff such as senior staff can reduce the risks of patient’s data being shared with external threats. You may want to also consider how staff can access data and implement access control measures such as passwords, pin numbers and key cards, this can be applied to accessing both digital and physical documents.

Secure offsite document storage is also a great advantage to medical practices when storing patients documents and data. This frees up space in the practice and restricts unauthorised staff from accessing confidential data. Furthermore, you can store years’ worth of documents, and this is a great benefit as full medical history documents can be retained, you never know when you may need them!

Secure document scanning will create digital copies of documents and these can easily be accessed by those who are authorised, this is a time saving advantage and helps your medical practice stay organised and efficient at all times.

Consider Record Management Plans

Furthermore, your business can develop a management plan that provides a clear understanding on how to manage records throughout their lifecycle.

The management plan should outline the way in which medical records are to be used, who has access to them, how they are kept and when and how they are destroyed.

In a world where there is a crossover between digital and physical, it is also important to develop a management plan for both paper records and digital records.

Developing a record management plan is a great way to ensure institutions and members of staff are complying with new laws such as the GDPR.

Creating your own individual company policy that communicates the key features set out by the law will guarantee that all departments are notified about the appropriate measures to take when collecting, retaining and destroying sensitive data.

Examine the environment

Paper records take up physical space and digital records take up storage space, so how do we minimise this whilst ensuring the maximum safety and protection of such records?

Whilst most files and records in the medical industry need to be on hand 24/7, there are certain exceptions such as back up versions that end up cluttering the office or reception area.

This is why many institutions choose to outsource such records to a document storage company where documents are safely stored in flame retardant boxes that are CCTV monitored.

Your document management plan should clearly explain the details of your medical document storage, including whether they are stored on-site or off-site and who has access to them.

An increasing number of healthcare institutions are utilising the services provided by document storage companies – this is because such companies offer a range of comprehensive and useful services including the storage, scanning and destruction of documents.

Storing data digitally can be risky – memory sticks and discs are prone to loss, theft or damage and authorised personnel should take extra precaution and create duplicate or back up data.

Consistent Classification

Within the medical industry, it is of the utmost importance that information is captured correctly, resulting in consistent classification.

The potential loss of records can be detrimental to institutions, especially doctor’s surgeries and hospitals where life and death issues are a part of the normal day.

Thankfully most organisations back up important information, however it doesn’t reflect positively on the institution or the service it provides should records continue to go missing. In order to ensure efficient retrieval, consistent classification should be a major feature in any medical record management plan.

Department organisation

All departments within the medical and healthcare sectors should be informed of the importance of the proper retention and destruction of all records.

All departments should follow a clear plan which includes which records should be retained initially, the minimum time of retention, the review process, how and when they should be destroyed and who is responsible for each set of records.

Ensuring that every member of staff within the institution is aware of proper document management measures to take will limit the chance of losing any sensitive data whilst increasing the efficiency of the entire process.

Recording Movement and Activity

Hospitals, doctor’s surgeries and other healthcare institutions can acquire a substantial amount of data over the years, and it is important that this sensitive data is recorded, tracked and monitored throughout its lifecycle.

Systems can be accessed that allow for the management of electronic documents – these systems record information such as who has accessed certain documents along with any changes that may have been made to individual files.

If healthcare institutions opt to outsource certain data to document management companies, such companies can use bar-coding systems that report all activity, giving complete peace of mind!

Healthcare businesses still heavily use paper

In most industry sectors, the costs of digitising paper records are far lower than the costs and risk associated with keeping paper records.

Healthcare, however, is somewhat different. While many types of documents can be successfully digitised other types of documents pose technical challenges and it can often be safer to keep these documents in paper format than to risk being unable to defend a legal challenge further down the line. CTG traces are a prime example of this.

Although these technical challenges may be overcome in future (or the legal issues rendered irrelevant by the passage of time), for the present, the need to secure paper is likely to remain a major issue for the healthcare industry.

How to destroy paper documents

When documents, data and files are no longer needed or used, it is important that sensitive information is destroyed properly and effectively without leaving any trace.

Your company policy should be in line with General Data Protection Regulations, stating the appropriate measures that should be taken throughout the destruction process and should also state the method of destruction. In order to avoid any legal complications, many institutions choose to outsource the destruction of sensitive data.

At RADS, we offer a document shredding service that includes a free collection and the confidential destruction of documents at a secure and CCTV monitored location. Digital records can also be recovered even after they are permanently deleted – instead hard drives should be physically shredded by a professional provider.

By following these steps and rules, you can be sure that you are handling and managing medical documents in the proper and lawful way. Appointing a Data Controller is a great way to make sure that the institution is doing everything in its power to obtain, retain and destroy the sensitive information of both patients and the business itself in an efficient way.

Let us help with your medical document storage

If you’re looking for help with storing any medical records or documents, please get in touch with the team at RADS. You can also request a quote to receive a free no-obligation quotation.