Hi Jeffrey,
It's not totally academic for two reasons,
[1] if it is not legally required to produce hard-copy reports and the ward
in question don't want hard-copy reports we could possibly write (software)
logic rules to prevent them being issued from the lab computer in the first
place (or get our lab computer software company to modify the software to
allow us to easily exclude individual sources for reports), and
[2] more and more of our wards have their own computer systems to which we
transmit laboratory results on a drip-feed basis (such as separate ICU,
Renal, Cancer, Diabetic and A/E systems along with a number of GP links to
various GP practices). Only the A/E system currently doesn't get lab results
returned electronically - we only use the A/E link to pull patient
demographics into the lab system (via the PAS system). All wards can still
access the lab results directly from the lab computer through terminals /
PCs whether or not they have their own computer system with down-loaded lab
results.
I'm not sure what you mean exactly by "...the secure, integrated EPR storage
in the hospital?". As far as I am aware there is no 'proper' EPR that
totally integrates all patient information, though I know the standards for
this are being developed at present. As far as the data on the lab computer
is concerned it is as secure as the IT department's normal procedures allow
it to be, i.e. the server is in a secure room and daily backups are
performed in a ?3-weekly cycle and removed off site to a fire-safe location.
"The rules apply to the original records, not their transcriptions, be they
paper or electronic."
Surely the electronic records ARE the original records?
I think as Jonathan has commented earlier...
"No-one knows if it is legally OK to only have computerised records"
means the answer to my original question is ... "we don't know - yet!"
Thanks again.
Billy.
-----Original Message-----
From: Jeffrey Davies [mailto:[log in to unmask]]
Sent: 22 August 2002 14:54
To: [log in to unmask]
Subject: Re: Retention of printed lab reports by wards
An interesting point, but academic as you do still issue paper reports, and
others on the mail base are probably more aware than I of the electronic
patient record issues. Do your laboratory computers form part of the secure,
integrated EPR storage in the hospital?
The rules apply to the original records, not their transcriptions, be they
paper or electronic. The only exception is microfilm/microfiche which is
acceptable in law as an exact copy. From memory, paper medical records (or
their immutable images) on adults are retained for at least 8 years from the
time they are last accessed; childrens' records are retained for at least 25
years.
Regards,
Jeff Davies
>>> "Graham, Billy" <[log in to unmask]> 08/22/02 02:06pm >>>
Hi Jeffrey,
Thanks for your reply and all those others I have received both via the list
and direct to my e-mail address.
I notice in the text you quoted that...
"Diagnostic records are properly retained in individual patient notes or in
electronic form..."
the bit I am interested in is the OR word...
"Diagnostic records are properly retained in individual patient notes OR in
electronic form..."
Does this mean it can be an either/or situation as I interpret it from your
quote?
In other words if the ward have their 'Diagnostic records', which I assume
covers lab reports, stored in electronic form (in most cases on laboratory
computer) they can dispose of the hard-copy reports (which brings me back to
the original question).
Regards, Billy.
-----Original Message-----
From: Jeffrey Davies [mailto:[log in to unmask]]
Sent: 22 August 2002 13:45
To: Graham, Billy; [log in to unmask]
Subject: Re: Retention of printed lab reports by wards
Dear Billy,
The College guidelines summarise admirably:
"Diagnostic records are properly retained in individual patient notes or in
electronic form, the safe keeping of which is the responsibility of hospital
records departments or recipient general practitioners or private
practitioners, once the pathologist has issued the reports. Where
pathologists have reason to doubt the reliability of systems of patient
record keeping, they should bring this to the attention of those
responsible rather than attempt to rectify it by duplication and local and
prolonged laboratory storage of diagnostic records."
The practice you describe is appalling and should be reported to your
hospital management.
Regards,
Jeff Davies
>>> "Graham, Billy" <[log in to unmask]> 08/21/02 04:52pm >>>
Hi,
Does anyone have information on how long wards must legally keep hard-copy
laboratory reports, if at all, assuming they will always be available
electronically via the lab computer (both active and historical records).
This query came to me from the nursing staff. Currently the ward in question
receives lab reports and the nurses filter out any showing 'abnormal'
results. The medical staff then look up these patient records in the lab
computer and take appropriate action. Following this, all the hard-copy
reports are filed away alphabetically in boxes dating back 7 years - the
reports are NOT stored with the patient record. These hard-copy archives are
taking up a lot of room and much staff time in operation of the filing
system.
I think if the retention of the hard copies is not a legal requirement the
ward would like to file them in the drawer labelled 'bin' rather than waste
time and space filing them as they currently do.
Any advice would be much welcomed.
Best regards, Billy Graham.
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