The background to this is:
1 The need to categorise different types of information. Correspondence on
patients was classified as part of the medical record, as were laboratory
reports. Internal workings, for example, were classified differently.
2 Legal advice was : "The best records are contemporaneous, and on paper."
Therefore this question boils down to " Do I need to keep an additional copy of
the correspondence once it is in the medical records?" and "Are the
computerised hospital medical records an adequate record system?"
Do I need to keep an additional copy of the correspondence once it is in the
medical records?
The College guidance says you don't have to. You need to decide whether you
want to in your own interests, taking into account both convenience and risk
management. The pragmatic advice would be to ask the hospital risk management
committee.
Are the computerised hospital medical records an adequate record system?
We're all going for "electronic patient record systems", but amazingly there is
no definitive answer to this question.
The pragmatic advice would be to ask both your medical records managers, and
the hospital risk management committee.
NB The current version of the College guidance is the 1999 document:
http://www.rcpath.org/activities/publications/retention.pdf
Jonathan Kay
"Hyde Philip (ULHT)" wrote:
> Just a quick question to help clear my mind on the topic of copies of
> correspondence regarding patients. The document published by the RCPath (The
> Retention and Storage of Pathological Records and Archives, Feb-95) states
> (p7) that "Correspondence on patients - Should be lodged in patient's
> record. Otherwise keep permanently." My correspondence files are all backed
> up on the Hospital main-frame which means (in theory) a permanent electronic
> record. Can I thus empty my dusty filing cabinet archive, storing those
> early records which are not on PC in a cupboard somewhere, and cease
> retaining copies ? What do you all do ?
>
> Philip Hyde
> Pilgrim Hospital,
> Boston (UK)
|