Workshop on Medical Records Management

Program overview:

A good medical record management system is essential for hospital management to provide quality treatment, continuity of care and data for decision making and research. Handling critical healthcare records confidentially, efficiently, and accurately while maintaining legal compliance is the backbone of quality treatment delivered to the patient.  This 5-day course on Medical records management” will walk participants through on the fundamentals of a good medical records management system and its sustainability that is legally compliant.

For whom:

This course is designed for staff of hospitals, clinics, and other long term healthcare facilities who are concerned with the day to day of management of Medical Records.

Learning Objectives:

At the end of this program, participants will be able to:

• develop a comprehensive medical record management system from generation of the record to analyzing the information in the records;
• establish a medical records department using best practices;
• organize medical records using IT- driven process;
• value a secured and efficient records management system;
• take a closer look at the realities of electronic records management (ERM);
• comply with the legal side of medical records management; and
• manage ongoing maintenance of medical records through effective filing system.

Course outline:

Day 1: The Fundamentals of Effective and Secure Records Management

• Purpose, value and need for medical records
• Understand how each piece of information is used and why it is important
• Conduct a system-wide inventory of your files and records
• Understand what you should keep, archive, or destroy
• Learn do’s and don’ts for proper and ethical record keeping
• Explore key differences in filing systems — decide which is best for your facility

Day 2: Planning for and creating a sustainable Medical Record System

• Ongoing Maintenance of Records in a Healthcare Setting
• Easy ways to increase productivity by making files more accessible
• Cross-check procedures that make employees accountable for the files they handle
• Build job aids to educate those with file access
• Establish a file archive that can be easily accessed

Day 3: Global Records Management Standard

• Numbering and filing systems including ICD code
• Data Index Method
• International Disease classification
• Introduction to Electronic Medical Records
• The truth: Does ERM save time or create more work?
• Applying information technology (IT) for records

management

• The Shortfalls and Successes of Electronic Records

Management

• What you must know if you integrate medical

records on the Internet

• Aspects to consider when selecting an ERM
• A simple way to determine how much access various

 staff members should have to records

Day 4: Records Department Administration

• Organizing Records by job and by function
• Safety and Security of Records
• Legal aspects of Medical Records development
• Quality Control in Medical Records
• Confidentiality and Release of Information
• Collection and preparation of reports
• Other Medical Record Clerk Functions

Day 5: Patient Confidentiality and Healthcare Records Management “The Law”

• Must-know rules regarding the faxing, copying, and filing of medical records
• Guidelines you can use to ensure you don’t delete or destroy vital records
• The safeguard you can implement to prevent unauthorized disclosures of health histories and medical information
• Recognize and eliminate the danger zones where security breaches occur most often
• The latest privacy requirements regarding medical records — what’s new from HIPPA that you must know

Training Methodology

Lectures, discussions, exercises, and case studies will be used to reinforce these teaching/learning methods.