Medical Record Management: Are You Gambling with Your Patient’s Health Information?
Medical Record Management: Are You Gambling with Your Patient’s Health Information?
When it comes to protecting patient health records, there are many considerations to ensure organizations are not left vulnerable to breaches. Establishing measures to ensure medical records are secure is critical. The Centers for Medicare and Medicaid Services (CMS) has established standards to help organizations safeguard medical records. If you are unsure about how information is being protected in your facility, then we highly recommend doing a deep dive into your facility’s current practices. Here are the areas that should be considered:
Access
- It is important for hospitals to establish and control access to current and historical medical records. Restricting access to only authorized individuals is essential. CMS requires that healthcare providers must be able to access historical medical records twenty-four hours a day. Additionally, healthcare providers should be able to access medical records for five years after a patient has been treated by the facility. Retention requirements may vary by state so be sure to know the retention periods required by your respective state. Historical data is essential in understanding past diagnosis, medical treatments and prior patient disposition. Access to information can also be helpful in developing current patient care plans and resources for continuity of care.
Audit
- Conducting internal audits to identify potential risks can be helpful in identifying area for improvement in oversight and management of medical records.
Security
- Encryption of medical records can help to prevent breaches from happening.
- Ensuring reliable server backup for Electronic Health Records is essential. Be sure to investigate systems in place to prevent loss of records. If vulnerabilities are identified, work with vendors and Information Technology specialists to eliminate risk.
Storage Requirements
- The condition of medical records storage areas should be protected from risk of water intrusion or fire. When selecting a storage location, healthcare providers should look at potential risk that could compromise the integrity of the records.
Training
- Education is a major factor in safeguarding your organization’s medical records. Ensure that team members understand all aspects of medical record management and comply with maintaining organizational safeguards. Release of information requests should be carefully managed by a designated Custodian of Medical Records. Logs should be maintained to reference release of records and known security breaches. If a breach is identified, be sure to immediately consult the Compliance Officer and Risk Management immediately.
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References:
OSHA's General Duty Clause and Ergonomic Risks Under Section 5(a)(1) of the Occupational Safety and Health Act (the General Duty Clause), healthcare employers are legally required to provide a work environment free from recognized hazards that cause or are likely to cause death or serious physical harm. Manual patient lifting, transferring, and repositioning represent significant ergonomic hazards. OSHA actively inspects healthcare systems for musculoskeletal disorders (MSDs) and mandates that hospitals implement engineered control solutions, such as ceiling lifts, sit-to-stand devices, and friction-reducing slide sheets.
The Technical Baseline: NFPA 99 Health Care Facilities Code NFPA 99 (2012 Edition, as mandated by CMS) establishes risk-based categories for electrical and gas systems based on the risk to patients. Category 1 spaces are those where procedures are performed that could result in major injury or death if utility systems fail. Under Chapter 6 (Electrical Systems), facilities must maintain isolated power systems (IPS) and line isolation monitors (LIM) in wet procedure locations to protect patients against electrical shock. Survey Vulnerabilities: CIHQ and Joint Commission Directives During surveys, both TJC and CIHQ closely inspect the testing logs for these specialized electrical environments. TJC Standard EC.02.05.01 requires facilities to manage utility risks, specifically focusing on the routine inspection of ground- fault circuit interrupters (GFCIs) and the regular calibration of LIM alarms. CIHQ surveyors frequently evaluate surgical staff on their understanding of the LIM panel: if an alarm sounds, do clinicians know that it signifies a critical loss of electrical isolation that could cause patient harm if a second fault occurs? OSHA 29 CFR § 1910 Subpart S Alignment While NFPA 99 protects the patient, OSHA Subpart S (Electrical Safety) safeguards the clinical staff operating the machinery. Employers must ensure all electrical medical devices are free from recognized hazards. Exposed wiring, unapproved extension cords, or failing to lock out/tag out malfunctioning medical hardware violates OSHA standards and places both employees and patients at immediate risk.
CMS Conditions of Participation (CoPs) and the Unified Focus The Centers for Medicare & Medicaid Services (CMS) establishes the baseline for safety through the Conditions of Participation (CoPs). Under 42 CFR § 482.41 (Physical Environment), hospitals must ensure that the physical plant is constructed, arranged, and maintained to secure the safety of patients. CMS holds leadership strictly accountable for ensuring that life safety deficiencies do not interfere with clinical intervention. When a surveyor enters a facility, they cross- reference the clinical patient logs with facility maintenance schedules to ensure environment-driven risks—such as positive/negative pressure room failures—did not impact immunosuppressed patients. Accrediting Bodies: CIHQ, Joint Commission and Other Aos’ Interventions Accrediting organizations like The Joint Commission (TJC) and the Center for Improvement in Healthcare Quality (CIHQ) act as the enforcement arms for CMS via deemed status. TJC’s Environment of Care (EC) and Life Safety (LS) chapters explicitly detail how physical space directly impacts clinical delivery. For instance, TJC Standard EC.02.03.05 requires hospitals to maintain and test fire protection and suppression systems, mapping directly back to Life Safety Code compliance. Simultaneously, CIHQ’s structural surveys place massive emphasis on a unified environment. CIHQ approaches physical plant standards as a direct extension of standard clinical operations. They emphasize that blocked egress corridors or improperly stored medical equipment don't just constitute technical facility violations; they are direct barriers to rapid code-blue response and emergency patient evacuations.
