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

Abstract

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