Preservation and Management of Clinical Records
Replacement Technologies
Currently, new technologies, such as digitization, are presented as a solution to avoid weeding microfilm when scanning documents. This attempts to solve file problems, especially space. However, keep in mind that the replacement of paper for other media (optical, magnetic, etc.) is only operational when applied to valuable documents. It is not applicable in the case of worthless documentation that will never be consulted.
If you want to perform a migration of these characteristics, it is necessary to determine, select, and delete documents deemed to have outlived their usefulness. Both digitization and microfilming are very costly due to:
- Materials
- Facilities
- Personnel
- Equipment
Also, consider that the lifetime of optical and magnetic materials is uncertain. It requires successive substitutions in modern media and changing the reading devices.
Legislation
Law 13/85 on Spanish Historical Heritage regulates the timing of transfer and preservation of documentation in administrative records. It sets a period of 5 years for records management (assets) and 50 years for the intermediate stage (liabilities). After 50 years, the historical file is transferred, where it is kept permanently.
If an institution’s archive cannot adequately protect the historical documentation that legally belongs to it, the transfer of documentation can be made by delivery record to a general archive, such as provincial historical archives.
Lifespan of Clinical Files
The conservation and transfer times for clinical documents vary materially from those set by Spanish law for administrative files. They are defined specifically in terms of variables that consider the population addressed and the type, operation, and infrastructure of the hospital.
The transfer of clinical documentation considered historic to provincial archives is not a common practice in the state. Weeding of documents is not usually done due to a lack of specific legislation.
In most cases, health centers cannot indefinitely retain their paper documents due to limitations of space and resources.
To resolve this issue, two types of action are currently being conducted:
- Outsourcing to companies outside the organization, in charge of conservation and historical liabilities.
- Miniaturization of medical records, consisting of microfilming or scanning the documents comprising the medical history. As a general rule, those records are deposited in the archives and historical liabilities.
The high cost of the second option leads health centers to preferably outsource their liabilities.
Lifecycle of Clinical Records
Active and Inactive Histories
Depending on their usefulness and frequency of use, the medical histories (HHCC) of patients treated at a health center can be active or inactive.
Active histories are those where the patient is currently visiting or receiving treatment, generating information recorded in their medical chart. Histories requested for research and teaching are also considered active, even if the patient has not visited the center or has died.
Inactive records belong to patients who have not had healthcare activity for a period and therefore have not generated information that has thickened their medical chart. Records of deceased patients not requested for research or teaching are also considered inactive.