The Challenge and the Goal: Regaining the Custody/Control of Outpatient Medical Records

Training Objective To improve the custody and control of outpatient medical records within the MTFs To prescribe procedures for maintaining the custody and control of outpatient medical records at the MTF To educate the MTF staff regarding their responsibility for the custody and control of medical records

Challenge/Goal Challenge Eliminating the unauthorized retention of outpatient medical records by beneficiaries Goal To ensure 95% availability of all outpatient medical records (ultimate goal of 100%) at all times

The Issue In 1999, Military Healthcare System (MHS) cited by DoD IG regarding the difficulty of locating outpatient records and the inability to validate workload Recent external coding audit reports cited a less than 50 % availability of outpatient records Hand carrying the outpatient record appears to be more of the rule versus the exception Consequences with the paucity of documentation regarding medical care raises accreditation questions and weakens confidence in the care

The Issue To address the issue, ASD (HA) directed the Surgeons General to ensure the accountability and control of health records are maintained by the MTF and not by the patients. Surgeon General sent out correspondence directing MTFs to institute robust local procedures to ensure that custody and control procedures exist for outpatient medical records

Why It’s Critical to Retain the Medical Record in the MTF Returning records to MHS control is critical to patient care and business decisions: - Communication link for continuity of patient care -Legal evidence for patient, physician, and the facility -Justification for reimbursement claims to third party payers -Information for disability and processing -Information to providers for quality assurance, evaluation, and improvement of treatment

What’s Required MTFs are directed to implement Record Management procedures that include the following: 95% Availability Closed medical record system Maximum utilization of CHCS MRT Tracking and reporting program to identify delinquent records Delivery of records to clinics for scheduled and walk-in appointments Secondary records Medical information forwarded for referrals to other facilities Storage and Security

Required: 95% Availability The medical records control process should include procedures to ensure 95% availability of all outpatient medical records (goal is 100%) “Availability” is defined as located within the MTF having functional responsibility for maintaining the record

Required: Closed Medical Records System BUMEDINST directs, Implementation of a “Closed Medical Record System” No hand carrying of records by beneficiaries Establish procedures to deliver medical records to the clinic for both scheduled and same day appointments Staff member are prohibited from returning the record to the patient’s control at the end of the clinic visit, except if the patient record label is maintained at another facility, Op Force command, or reserve unit

Required: Medical Record Tracking (MRT) The CHCS MRT module will be used to the maximum extent possible by both records and clinic personnel –Record personnel pull records 1 or 2 days in advance of the patient’s appointment and delivered to the clinic. The record is scanned into MRT and logged out to the clinic –Clinic personnel are responsible for logging in each outpatient record and retaining it after the appointment. –Records returned or pick-up at the end of the day –Clinics which do not return records within 5 working days are put on the delinquent list.

Required: Delinquent Record Tracking The MTF will establish a tracking and reporting program to identify delinquent records. Records that has not been officially signed out that is missing from the MTF Record that is officially signed out to a provider, clinic, service or person and not returned within 5 working days Records 30 days delinquent will be forwarded to the Medical Records Committee (MRC) or higher authority for resolution

Required: Secondary Records A Secondary record will be retained at the site where the healthcare is provided - For beneficiaries who records are maintained by other sites (i.e. ship, squadron, reserve unit, network PCM), a secondary record will be retained in the clinic where the healthcare is provided. - Maintenance and disposition of the secondary record will be followed in accordance with the guidelines outlined in Chapter 16 of the Manual of the Medical Dept. and the local Medical Records Committee

Required: Medical Information Forwarded For Referrals Procedures must be established for care referred outside the MTF - A process must be developed to forward clinical documentation when the beneficiary has an appointment outside where the record is maintained - Patients may only take their consults and documentation specifically related to their consults to appointments at other MTFs or Network Providers - Patients are not authorized to hand carry their medical record to appointments at other MTFs or civilian facilities. There are no exceptions to this!

Required: Storage and Security The MTF must ensure that records are protected against loss, destruction, tampering and unauthorized access or use, Take necessary precautions to avoid compromise of medical information during the movement of records within and from the MTF Restrict access to medical records to authorized medical service personnel Keep medical records in a locked area, room, or file to ensure safekeeping, unless there is a 24-hour watch in the records room Provide the same level of security when records are removed from the records room to a clinic, health care providers office or inpatient area Use of cipher locks on medical records room

Exceptions: Op Forces and Reserve Units Op Forces, Reserve Units……. Op Forces Commanders and Reserve Units are designated as the custodian for medical records of those members assigned to their command To facilitate appropriate care when Op Forces and Reserve Component (RC) members are referred to an MTF, the Op Forces/RC members are allowed to hand-carry their medical records from their command to the MTFs and are allowed to retain possession of their record at the end of the care. MTFs must support this exception to policy by placing all documentation of the patients episode of care into the health record prior to the patient leaving the MTF

Exceptions: PCS Moves PCSing Active Duty and family member outpatient medical records may be hand-carried to the next MTF with a copy of the PCS orders and appropriate medical release. Outpatient medical records of any adult family member or spouse may be release to the sponsor or spouse provided written authorization is given

Measures of Effectiveness Monitoring will be accomplish via: Monthly Commander Statement Med IG Management Control Program External Audits CHCS MRT Delinquent Records Report

Everyone is Responsible!! Every staff member (medical record staff, clinic staff, providers, techs) is responsibility for maintaining the custody and control of medical records at the MTF Every staff member must be aware of and engaged in the procedures outlined to retain and maintain medical records within the MTF

References OASD (Health Affairs) Custody and Control of Outpatient Medical Records at Department of Defense Military Treatment Facilities memo dtd 22 Jul 03 BUMED’s Custody and Control of Outpatient Medical Records at Department of Defense Military Treatment Facilities ltr dtd 16 Sep 03 Manual of the Medical Department, Chapter 16