Top 5 things to know about record management

medical record management

Record management, also called RIM, or records and information management is the practice of maintaining and organizing records in a certain field or industry. Though many fields require some system of records management, it is particularly important in fields such as the medical field. People who manage records have difficult jobs. They must not only keep track of a highly complex system of organization but are constantly around sensitive information and documents. In a smaller company, a records manager may be able to keep a spreadsheet of records, but in larger companies, a records manager may be required to learn and utilize difficult software to manage and track necessary records. Here are a few things that are important to know about record management:

  1. Record management is specifically designed to track the life of the record. What does that mean? It means that from the initial creation of the record all the way through the time it is destroyed if it has reached the agreed upon length of time it needs to be stored for.
  2. There are lots of steps in medical record management. This includes initial entry, classification, storage, tracking, retrieval and additional maintenance as necessary. Once a record is identified and stored, it does not mean it is forgotten about until it is destroyed. There are numerous times a record may need to be retrieved or updated for certain purposes like audits.
  3. Lawyers often utilize medical record retrieval when they are working on a case that could depend on certain medical issues, timeline, fraud or more. Lawyers will often use companies such as MRC Houston who can do the legwork of getting the appropriate documents that can help with a case. When there is appropriate documentation, lawyers are able to use these records as evidence to prove things such as a timeline of events or anything about a client’s medical state or medical record.
  4. Not all documents are considered records. Contrary to popular belief, not every scrap of paper, email, note or list is considered a record. By definition a record actually only tracks activities or transactions made within a company or client relationship. Think of a record as evidence that something was agreed upon or something happened. In the medical industry this can be work orders for certain procedures or perhaps even receipts of payment from a patient.
  5. Records have what is called a “life cycle” and it is broken up into phases. Phases include the creation phase, when the record is entered, the modification phase when any changes need to be made, the movement phase when the record needs to be moved to a new country or state and the destruction phase when a record can be destroyed after a previously agreed-upon timeline by the institution.

As you can see, record management is an extremely crucial component to an institution and the institutional memory. When records are managed properly, it can provide a detailed timeline of everything that happened in an organization and provide correct details in the event of an audit.