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

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The Challenge and the GoalRegaining the
Custody/Control ofOutpatient Medical Records
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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

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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

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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

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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

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Why Its 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

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Whats 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

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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

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Required Closed Medical Records System

• BUMEDINST 6150.38 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 patients 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

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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 patients 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.

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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

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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

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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!

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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

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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

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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

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Measures of Effectiveness

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

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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

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References

• OASD (Health Affairs) Custody and Control of
  Outpatient Medical Records at Department of
  Defense Military Treatment Facilities memo dtd 22
  Jul 03
• BUMEDs 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