Healthcare Records Management: Retention and Lifecycle
Introduction to Healthcare Records Management
A healthcare organization (HCO) bears the legal responsibility for all clinical documentation generated and stored, whether on-site or externally. The HCO must ensure the security and integrity of these records. Procedures must be in place to prevent loss or destruction, guarantee security, and monitor storage conditions during both active and inactive periods, organized as comprehensively as possible.
Documentation custody encompasses:
- Conservation and preservation of documents.
- Suitable spaces and facilities for archival treatment.
Proper document custody facilitates user access and enhances the quality of archival work.
1. Document Conservation
Document conservation involves procedures and measures to establish:
- The lifecycle of documents.
- Document retention periods.
- Transfer schedules.
- Criteria for elimination or permanent retention.
- Conservation methods.
As documents generated by an institution lose value and are no longer needed for daily activities, they may be transferred to other files, destroyed, or repurposed using new technologies.
1.1 Document Lifecycle
The document lifecycle consists of stages a document passes through, from creation to either removal or permanent preservation. In an institution, the document lifecycle has three stages:
- Current Utility Period: Documents frequently used for managing the organization’s affairs.
- Interim Utility Period: Documents that have outlived their immediate usefulness.
- Definitive Utility Period: Documents permanently retained for their informational, historical, and cultural value.
A document’s value can be primary or secondary, depending on its purpose.
- Primary Value: Directly related to the immediate purpose for which the document was produced.
- Secondary Value: Related to motives other than the document’s original purpose, such as historical or informational value.
2. File Phases
- Active File (Management): Subject to continuous utilization and consultation. (Higher primary value, current utility period)
- Intermediate File: Documents transferred from active files when their use becomes sporadic, awaiting elimination or transfer to the historical archive. (Lower primary value; interim utility period)
- Historical Archive: Documents transferred from the intermediate file for permanent retention, having been deemed worthy of preservation by competent committees. (Secondary value; final utility period)
3. Expungement
Expungement involves the controlled partial or total removal of documentary material. It is linked to the concepts of document lifecycle and file phases. Regulations govern expungement, dictating retention periods at the point of origin and transfer to an intermediate file, where documents are either destroyed or transferred to the historical archives for final expungement.
Conservation efforts aim to reduce the volume of documents, retaining only the minimum necessary for current or future informational needs. A document lacking both primary and secondary value can be considered useless and eligible for elimination if its preservation costs outweigh its benefits.
Weeding involves assessing the quantity and quality of information to decide whether to destroy or permanently preserve documents. Document destruction is irreversible. To avoid personal responsibility and errors, legal frameworks regulate weeding through sector-specific legislation, regulations, or binding guidelines at various levels of government.