10.3 Medical Records

Part II: Guidelines for Client Services and Clinic Management

  1. General Guidelines:
  2. Medical Record Content:
  3. Confidentiality and Release of Medical Records:
  4. Medical Records Security:
  5. Medical Records Retention:
  6. Record Monitoring:

General Guidelines:

Client medial records must be maintained in accordance with accepted medical standards and State laws with regard to record retention. Delegate agencies must establish written protocols and operating procedures for medical records that include the following:

  • Each client who receives medical services must have a medical record (this must include all pregnancy testing/counseling clients).
  • Medical records must be available to the client upon request.
  • Medical records of clients must be maintained in accordance with the accepted medical standards. Medical records must be:
    1. Complete, legible, accurate, and written in ink;
    2. Uniform in content and format;
    3. Signed by the physician or other appropriately trained health professional making the entry, including name, title and date;
    4. Readily accessible;
    5. Systematically organized and in chronological order to facilitate retrieval and compilation of information;
    6. Confidential;
    7. Safeguarded against loss or use by unauthorized persons; and
    8. Secured by lock when not in use.
  • HIPAA regulations regarding medical records must be followed.

Medical Record Content:

Delegate policies regarding the content of the medical records must include:

  • Complete and accurate information to identify the client;
  • Indicate where and how the client can be contacted;
  • Confidentiality assurance statement;
  • Informed consent for services and method specific consent per IDHS guidelines;
  • Documentation of medical telephone encounters;
  • Date and signature of the clinician or other appropriate health care provider making the entry:
    1. Signature contains name and title, and
    2. A signature log must be used if full name and title is not used in medical record
  • Personal data:
    1. Name
    2. Address, phone number, and how to contact
    3. Age
    4. Sex
    5. Income eligibility (income information should not be a barrier to service)
    6. Number of pregnancies, abortions, live births
    7. Unique client number
    8. Race and ethnicity
    9. Need for an interpreter or other special consideration (e.g. accommodation for disability)
  • Medical history;
  • Allergies and untoward reaction to drug(s) recorded in a prominent and specific location;
  • Results of physical exam;
  • Reports of clinical findings, diagnostic and therapeutic orders;
  • Laboratory test results and follow-up done for abnormal results;
  • Treatments initiated and special instructions and scheduled revisits;
  • The contraceptive method chosen by the client;
  • Documentation of all counseling, education, and social services given;
  • Refusal of any service;
  • Problem list at the front of the chart listing identified problems to facilitate continuing evaluation and follow-up; and
  • Documentation of continuing care, referral, follow-up and scheduled revisits.

Client financial information, other than income eligibility information, should be kept separate from the client medical record. If financial information is included in the medical record, it must not be a barrier to client services.

Confidentiality and Release of Medical Records:

A system must be in place at the clinic to assure the confidentiality of client records. A release of the client's medical record information can occur only with client's written consent, except as may be necessary to provide services to the client, or as required by law. Adolescents have the same rights to confidential services as any client.

Delegates must have a consent form for the release of medical records. Prior to the release of records, the consent form for release of information must be signed by the client and must specify to whom information may be disclosed and what specific information may be disclosed. Only the specific information requested may be released.

Prior to the release of any information in response to the serving of a subpoena, the delegate agency must contact their agency's legal counsel for guidance.

HIV, mental health and substance use information should be handled according to law and released only with the specific consent of the client.

Delegate agencies must have a policy and procedure for allowing the client access to their own record.

Information collected for reporting purposes is disclosed only in summary or statistical form.

Medical Records Security:

Medical records are confidential and must be safeguarded against loss or use by unauthorized persons. All personnel, students, volunteers, auditors and program consultants and reviewers must execute a written confidentiality agreement before obtaining access to medical records. Refer also to Section 6.6 on training new or volunteer staff on confidentiality.

Medical records must be kept locked in secure files unless they are under the supervision of an employee who has a business need to see the medical record.

Medical records rooms will be locked after regular working hours.

Medical records must be secured in locked cabinets during the time the janitorial service cleans the area where records are stored.

Medical records being used by staff over a period of time must be kept in locked cabinets after regular working hours.

Fax machines must be placed in an area where staff may supervise and safeguard the medical record information that is sent from other providers regarding clients.

Records not filed after clinic hours, to be reviewed by employees the next day, must be kept in locked files.

Medical Records Retention:

The agency must have policies in place regarding the retention and destruction of medical records. For advice on record destruction, agencies are to contact agency legal counsel, or in the case of public entities, the Illinois Secretary of State's Illinois State Archives. Family planning clinics must retain all records, documents and correspondence relative to medical services for a period determined by agency legal counsel. Records may be stored in inactive or closed files per agency policies.

Records of minors shall be retained for a period past majority determined by agency legal counsel. Records of clients receiving contraceptive devices (implants, IUD/IUS) shall be kept indefinitely.

Record Monitoring:

Monitoring of client medical records must be periodically performed. (Refer also to Section 10.4, Quality Assurance, on quality monitoring of medical records).

Concurrent medical record monitoring should be performed after each clinic session by consistently assigned staff. There should be a system in place to identify medical record deficits and to resolve identified problems.

Periodic medical record audits must be conducted. Audits should randomly sample records of new patients, continuing patients, teens or method specific users for compliance to medical practice and documentation standards.

Family planning clinics must comply with audits of medical records and documents that may be conducted at any reasonable time by State and Federal personnel or other persons duly authorized by IDHS. This may include the review of client medical records, delegate policies and procedures, personnel records, job descriptions, and meeting minutes. All reviewers and auditors accessing delegate agency records must sign a confidentiality agreement.

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