Investigation of retention and destruction process of medical records in the hospitals and codifying appropriate guidelines

نویسندگان
doi
چکیده

Introduction: One of the major issues in hospitals is the period for which the medical records areretained. Health information management professionals traditionally have performed retentionand destruction functions using all media, including paper, images, optical disk, microfilm, DVD,and CD-ROM. Health information management departments must maintain a specific programto retain and destruct the records. The purpose of this paper is to investigate the retention anddestruction process of medical records in the hospitals in Isfahan and codifying the appropriateguidelines. Materials and Methods: The research was conducted as a cross-sectional descriptivestudy in 30 hospitals in Isfahan. The data was collected using a Check List. Also 30 medicalrecords experts’ viewpoints were obtained using the Delphi technique. Data entry and statisticalanalysis was performed using SPSS. Results: The findings indicated that 53.8% of the studypopulation maintained a written policy. A 34.6% maintained a written policy to destruct medicalrecords. And 50% announced that no instructions had been given to the hospitals by qualifiedauthorities to destruct the medical records. Discussion: The majority of the hospitals are stillunclear about the retention period of medical records, which could be due to not to mention theretention period for most medical records by the country’s National Literature and lack of policyand procedure in hospitals. Conclusions: According to the legislations, hospitals are bound toretain the inpatients’ records for full 15 years but based on the findings of this research, less thanhalf of the study population retained the inpatients’ records for the period mentioned.

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