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A comparative study of laws and procedures pertaining to the medical records retention in selected countries
Nahid Tavakoli1, Sakineh Saghaiannejad, Mohammad Reza Habibi
1Isfahan University of Medical Sciences, Isfahan, Iran.
Introduction:
The health record serves several purposes and must be retained to meet those purposes. These varied purposes influence how long health records must be kept, or their retention period.
Aim:
Present study aimed to recognize laws and procedures pertaining to retention of health records in selected countries and provide a proposed guideline for Iran.
Methods:
This was an applied and descriptive-comparative research on laws and procedures pertaining to retention of medical records in USA, United Kingdom, Australia and Iran that performed in 2011. The data were collected via library sources, websites, and consultation with specialists in and out of the country. The validity of the data was confirmed by experts. Finally, the recommendations were provided for medical record retention in Iran.
Results:
The study revealed that, there are complete and transparent record retention schedules in selected counties so that retention situation for adults, minors, emergency, outpatients and deaths records is clearly recommended. But in Iran, either there aren't specific laws and procedures for medical record or they are unspecified.
Conclusion:
The lack of a complete, transparent and update medical record retention schedule in Iran, lead to confusion for hospitals. Some of hospitals maintain medical records more than of determined retention period and some of them destruct them before expiring of essential retention period. In order to optimize the situation of health records retention in Iran, it is necessary to review, correction and correction and completion of medical records retention schedule on the provided recommendations for kinds of medical record.
Related Concept Videos
Purpose of Health Records I
Here's a breakdown of how health records serve these purposes:
Legal Guidelines for Documentation
Methods of Documentation I: Source-Oriented Records
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:
Purpose of Health Records II
Types of Records II: Educational and Administrative Records
Methods of Documentation VII: EMR
