Part Two
- Medical records protection and disposal policy
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Policy: protection of medical records and information from loss, damage, tampering and unauthorized use
Purpose: to ensure the preservation of the medical file from being lost or damaged and to ensure the preservation of the patient's medical information for retrieval when it is needed .
Actions:
The medical record keeping room at the hospital meets the following specifications :
* Ventilation is sufficient .
* Lighting is sufficient .
* Fire Protection .
* Keep shelves intact .
* Offices for employees .
* Access to the place of filing is not allowed to non-authorized persons (patient affairs staff only) .
* The medical records bureau officer keeps the patient's medical records on the shelf in the order of the month for each department.
* The medical records office Officer repairs all records with loose papers or torn covers immediately before the important information recorded in them is further lost or damaged.
* The official of the medical records office saves all reports related to diagnostics, examinations, etc., such as medical reports or laboratory results... In the medical file, except for radiology, it is kept in the radiology department .
ยท There is a record of recording requests in the place of filing files, including borrowed files and the person who borrowed the file from authorized persons to view the file .
* The responsibility of maintaining the cleanliness of the place and the proper arrangement of files on the shelves lies with the medical records clerks assigned to work in the place of filing files.
Responsible : medical records office
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Purpose:
to dispose of medical files by legal methods and clarify the legal period for keeping records and files .
Politics:
* Disposal of records within the specified period in accordance with regulations and laws.
* Get rid of the records completely to prevent them from being viewed by anyone or extract identical copies from them.
* Records may not be disposed of except on the basis of an administrative order issued by the director general of the hospital.
Actions:
* Inactive medical records may be disposed of after the expiration of a certain period of time determined by the guidelines of the Ministry of Health.
* Records to be disposed of must be recorded according to the patient's name, medical file number and the last date of activity.
* Records must be completely disposed of to prevent them from being viewed by anyone or to extract identical copies from them.
* On the first of December of each year, the medical records officer and a clerk review the medical records to extract what has expired from the prescribed periods of preservation and deserves to be dispensed with Permanently' in accordance with' the guiding policies of the Egyptian Ministry of Health website.
* The medical records officer keeps all records related to lawsuits or other investigations of a confidential or serious nature and does not dispose of them until after the completion of lawsuits .
* On the first of January of each year, the medical records officer examines the dispensed documents and after confirming the validity of the dispensing, they are packed in bags by the Department's workers to be handed over to the Directorate of Health Affairs for disposal in accordance with the' archives regulation '.
* The schedule for maintaining medical files and records is as follows .
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In charge
* Medical records department
References
* Directory of medical records of the Ministry of Health
* Guiding policies of the Egyptian Ministry of Health website.
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