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Part Two

- Medical records protection and disposal policy

Policy for protecting medical records and information from loss, damage, tampering, and unauthorized use or access

Policy name

Protecting medical records and information from loss, damage, tampering, and unauthorized use or access

Policy number

 

Issue date and number

 

 

Review Date

 

number of pages

 

Section

Medical records department


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 .

· 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

Preparation

review

The trust

 

 

 


Policy for disposing of medical files and the duration of keeping records and files


Policy name

Disposal of medical files and the duration of keeping records and files

Policy number

 

Issue date and number

 

 

Review Date

 

number of pages

 

Section

Medical records


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 .

Schedule for maintaining medical records

Name of the medical record

Duration of retention of the original record

In years

As of the date of

Using the computer for permanent preservation

Log in and out

2

Record the latest case

no

Emergency department record

2

Record the

no

Transaction log

2

Record the latest case

no

Record of radiology examinations

2

Record the latest case

no

Record laboratory tests

2

Record the latest case

no

Any other record

2

Record the latest case

no

 

Timeline for maintaining medical files

the topic

Retention period in years

As of the date of

Using the computer for permanent preservation

Patient's medical file

5

Last patient review

no

Radiology films

5

The patient's last imaging request

no

In charge

* Medical records department

References

* Directory of medical records of the Ministry of Health

* Guiding policies of the Egyptian Ministry of Health website.

Preparation

review

The trust