Records Control in Healthcare One Thesis

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' Since the paper is only used as 'back up' this means that the files are under lock and key, in a centralized location or in the department generating the data. They do not circulate throughout the facility, ensuring a greater chance of misplacement or security compromises. But even in this instance, errors can occur -- timely record-updating and writing times and dates next to new information when it is added to a patient's file is essential, to ensure that there is not a discrepancy between the patient's data kept in two different locations. In fact, one worker at one of the larger facilities expressed dissatisfaction with the paper back-up method: "Keeping everything together either electronically or on paper not both. Causes too much confusion," she or he wrote.

Unfortunately, in large and small facilities, even with security procedures such as password protections for digital data, safety concerns remain. Concerns about compromised patient safety were often expressed by workers and the danger of legal violations for the facility because of lack of compliance with government regulations even if no malfeasance was intended. There were also concerns about misinformation about drugs and patient drug interactions because of incomplete patient data. If data is lost, patient safety can be compromised. Having to recreate a lost file can be difficult when there is insufficient or contradictory back-up information. Also, some facilities do not keep files on former patients, which can be a problem if a patient contracts a condition which requires him or her to find out past information about his or her medical history.

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Most larger facilities have standardized operating procedures about when medical records are destroyed, such as doing so after every ten or five years, notifying a patient when this takes place, and giving a patient the option to obtain the records if they show an identifying card, but others do not, or do not inform patients of these procedures.

Interestingly, none of the respondents, however difficult the computer procedures might be, and no matter what concerns they might have about patient confidentiality, expressed a preference for paper-based records. Except for one facility that was extremely small, all of the workers at small, paper-based facilities said that they desired a shift to digital technology, although they expressed the hope that appropriate safety controls would be instituted and it would make sense in terms of how data was recorded, either numerically or alphabetically or both. The primary complaint at larger facilities that were totally digitalized were the lack of appropriate security systems, and inaccurately entered data, or discrepancies between back-up data and the data on file. But the easy searchability of the digital format, and the ability to transfer records quickly to a new point of care outweighed the legitimate observations of many of the respondents to the new, digitalized world of medical record-keeping.

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