Document Type : Original Article
Authors
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.
Keywords
USA: W.B Saunders Company; 2002.
2. Rinehart-Thompson LA. Storage media profiles and health record
retention practice patterns in acute care hospital. Perspect Health
Inf Manag 2008;5:9.
3. Abdelhak M. Health information managing of a strategic resource.
2nd ed. 2007.
4. Tabibi J, Ebadifard A, F. Safdari, R.Hajavi, A.Meydani, Z. Health
Information Management Standards; Ebadifar, Tehran, 2004. [In
Persian]
5. Daniyali A, Keshtkaran A. Medical record management. Shiraz
University of Medical Sciences, Taavoni Nasheran- e- Fars, Shiraz,
2001.
6. Susan R, Susan K. Medical Record Management. Fam Pract Manag
2001;8:45-54.
7. Mann R, Williams J. Standards in Medical Record Keeping. Clin
Med 2003;3:329-32.
8. Rinehart-Thompson LA. Record retention practices among the
Nation’s “Most Wired” hospitals”. Perspect Health Inf Manag 2008;5:8.
9. National Health Services Code of Practice. Record management.
London: Department of Health; Available from: http://www.dh.gov.
uk/publications. [Last cited in 2008].
10. Meydani Z. A comparative study on medical record standards in
selected countries, Msc thesis. Tehran: Iran University of Medical
Sciences; 2004.
11. Pullen I, Loundon J. Improving standards in clinical record-keeping.
Adv Psychiatr Treat 2006;12:280-6.
)