Document Type : Original Article
Authors
1 PhD Student of Health Information Management, Health Management and Economics Research Center, School of health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
2 Lecturer, Medical Informatics, School of Health Management and Information Sciences, Iran University of Medical Sciences Tehran, Iran
3 BA , Nursing, Office of Hospital Management and clinical service excellence, Vice-Chancellor for Treatment, Ministry of Health and Medical Education, Tehran, Iran
Abstract
Introduction: Compared with the leading countries in the field of health information management, the current laws for medical record retention in Iran are very general, vague and they are inappropriate in terms of medical records usage, and there is not any reference to retention of many special medical records. Thus, the aim of this study was to revise the medical records retention laws for hospitals in Iran. Methods: This was an applied study which conducted in four phases from 2012 to 2013. In the first phase the study population consisted of all hospitals in Iran (890 hospitals), respectively, and in other phases of the study the consisted population were experts in the field of medical records. Instrument for data gathering was questionnaire. Data were analyzed by using descriptive statistics in SPSS software. Results: The highest volume of requests for medical records in hospitals in Iran were related to legal purposes and patient continued treatment, and the lowest was related to research and educational purposes, respectively. Overall, hospitals identified 39 cases of medical records to revise in laws for retention. Type of admission, patient age, type of medical records usage were the most important criteria for determining the period of medical records retention. A retention period was considered for 27 types of medical records, of those 19 cases approved by National Archives of Iran. Basic retention period for inpatient medical chart was considered 10 years from the last patient encounter. Conclusion: The laws for medical record retention in Iran were revised. In comparison with pervious laws, the new laws consider more the legal, treatment, research aspects of medical records and the right of underage patient.
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