Records commonly include personal identification information, exam findings, allergies and drug sensitivities, hospitalizations, surgeries, prescribed medications, clinical tests, pregnancy history, test results, health history, and progress notes.
medical record, electronic health record (EHR), electronic medical record (EMR), physical data entry electronic medical record (PDE-EMR), health record, medical chart
Typical Storage Media:
- medical chart (paper chart)
- radiological film (x-rays)
- recording strips (ex. EKG, EEG, fetal monitor)
- cine films
- pathology slides
- paraffin blocks
- patient account records (billing and insurance records)
For additional information regarding storage media, to view a resource page from the American Health Information Management Association (AHIMA).
(1) Rockart, John F. (1972). “Medical Record Storage: A Method for Determining Level of Activity,” Health Services Research.
(2) “Practice Guidelines for LTC Health Information and Record Systems,”American Health Information Management Association (AHIMA), 2008.
(3) Taylor, Shelia. (2000). “Tight Squeeze for Paper Records,” Canadian Facility Management and Design.
(4) Clark, Jean A. (2004) “Documentation for the Acute Care,” AHIMA.
It is critical that each medical facility have a formalized system for the maintenance and organization of their medical records. All records should be consistently organized and readily accessible. The guidelines below offer a baseline for the systems that should be in place for maintaining the records systems in a facility.
It is important that active and overflow records are maintained in a consistent, organized manner. Records are to have an established order of filing that is followed. All records (overflow records, records on the nursing station, and discharge records) should be readily accessible, kept in an organized chart order, filed in an easily retrievable fashion, and retained in folders or chart holders adequate in size for the volume of the record. The folders and chart holders should be kept clean, neat, and orderly.
Legally, each page or individual document in a medical record should contain identification information including at least patient name and medical record number. If the facility uses labels or label paper, patient information should be included on the label. The patient name and number should be placed on both sides of a document because records are often copied and both sides may not be included. Identification information can be written on the records using permanent ink, stamped with an addressograph, or affixed with a label.
The health care organization’s filing systems, policies, and procedures must comply with federal and state regulations to ensure that all health records are well organized and available in a timely manner to all authorized users. Policies and procedures must be in place to provide the prompt, consistent, uniform, and efficient filing of all health records. The system of filing should ensure the safety, security, and accuracy of health care records. The retrieval system should be structured to ensure the safety, security, and accuracy of health records. Measures must be in place to keep track of the location and holders of health records and to follow-up at appropriate intervals on the return of the health records. Procedures must also be in place to identify the health records that need to be converted to a different medium and moved to inactive storage or destroyed. (1)
Medical records, or healthcare records, are generally in two forms – paper and electronic. Each has its limitations. The federal government has mandated that all health care information will be stored electronically. However, there will still be paper-based medical records around for quite some time.
Source-oriented – like documents are grouped together (i.e. labratory reports, radiology, physician’s progress notes, etc.) Usually filed in reverse chronological order.
Problem-oriented – arranged according to problem/occurrence. Each problem/occurrence of the patient is indexed with a unique number. All reports, clinical documentation, progress notes, care plan, and other patient data are identified with this unique number. It is then generally arranged in reverse chronological order sections, each which covers a specific problem/occurrence.
Integrated – All documentation from various sources is intermingled and follows either chronological or reverse chronological order.
Results of the health record evolution. Solves many of problems that affect paper-based medical records.
True EHRs are not just digitized paper records, but rather the capture of data with the capability of retrieval of that data using electronic technology to allow full functional decision support. The system must also protect the security of the patient identifiable information and the integrity of the clinical documentation, as well as, be available for multiple users at the same time. Most healthcare organizations today store the digital version of the paper records. Experts say this is the first step to true EHRs.
There are several numbering systems used for medical records. The most common are serial, unit, and serial-unit.
Serial – Each patient is assigned the next number in the series. If the patient is admitted multiple times, each time a new number would be assigned for that admission. A patient would have completely separate records making it difficult to compare information from the different admissions.
Unit – Each patient is assigned a unique number on the first admission, and it is used for each subsequent admission. All records are filed together saving cost and labor. However, during the admission process, the facility’s master list must be checked to make sure the patient does not already have a number.
Serial-unit – Uses both the serial and unit system. In this system, the staff assigns the next number in the series. Any records from previous admissions are retrieved and combined with the current one. When the current admission is complete, all the records are stored under the most recent number.
Alphabetical – Generally used only in small facilities/clinics or single physician offices. In this system the patient record is filed by last name, first name, and middle name. The birth date is commonly used to differentiate between duplicate names.
Numeric – Filed in a numeric sequence. Used in larger facilities that have high patient volume. This system relies on a master patient index that lists the patient’s name and the record number.
Purges are generally done by year using the discharge or “last seen” date.
Lateral file cabinets – Used in smaller facilities, but do not make good useage of expensive floor space. While better than vertical file cabinets, they still require additional footprint space. There are automatic lektreiver systems similar to vertical file cabinets where shelves are on a rotating drum and rotate to access the various shelves.
Fixed open shelf systems – Most common system. These systems consist of open racking with space allowed for aiseles to access the files. The folders have side tabs for easy retrieval.
High density mobile systems – These are also called compressible. They are like the fixed open shelf systems except that the shelves are on tracks in the floor and can be moved and opened as necessary to access the records. These are good for high patient volume and where floor space is at a premium.
Microfilming paper records will reduce the amount of storage space substantially. It is good for inactive or infrequently used medical records. However, not good for active or frequently used records.
Source documents are scanned to disk (optical or hard drives on servers) as images. Access is easy and fast, and it is available to multiple users at the same time. These systems are capable of scanning thousands of images in a day. The images can then be loaded into EHR systems. (4)
When it becomes necessary to move inactive medical records to offsite storage, storage boxes are used. Boxes used should be of adequate quality and durability for record storage purposes. It is best to stack no more than three boxes high to maintain the integrity of the boxes. Boxes should be placed on shelves to facilitate easy retrieval. They should not be placed on the floor. Boxes should be at least 6″ above the floor and 18″ below sprinkler heads.
One of the most important physical security measures that must be in place at every medical facility is a record sign-out system for all medical records. Not only should these systems be in place, but they must be enforced to be effective. Health information staff should monitor the sign-out practices and assure that records are returned in a timely manner.
Active Records – Outguides or a sign-out system must be in place. Charts should not leave the storage location without being signed out. Outguides work well because they are placed where the chart was removed. The authorized person who took the record must be identified along with the date and location.
Inactive Records – Regardless of where inactive records are located in the facility, there must be a sign-out process to identify when a record has been removed, who took the record. and where it is located.
HIM (Health Information Management) Standard
The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that requires health care facilities who utilize standard transactions (such as electronic billing) to comply with the Standards for Privacy of Individually Identifiable Health Information (HIPPA Privacy Rule). This section refers to various components of the privacy rule, but does not go into full detail on all requirements. It is recommended that health information practitioners obtain a copy and review the entire HIPAA privacy rule. Copies can be obtained through the Administrative Simplification web site at http://aspe.os.dhhs.gov/admnsimp/