RS-ORM220: RECORD KEEPING

SUBMITTED BY: ALICDAN, CLAIRE ANN M.

RONCALES, JAMES LEANDRO P.

Develop your own Record keeping, Storage, Retrieval and Disposal policy using the template below:

Policy Context
To regularly monitor clients', patients', employees' and the company's information for proper
management. Kinesis Center aims to ensure the success of the organization by controlling the growth
of records, retaining relevant data, enabling regulatory compliance, keeping sensitive data protected,
and having a unified records management system.
Record TypeS:
1. Clinical
 Referrals
 Evaluation forms
 Specialized forms
 Progress notes
 Problems oriented record
 Multidisciplinary progress notes
 Discharge summaries
2. Administrative
 Departmental data and statistics
 Personnel Records
 Financial Records
 Equipment Records
Record Formats
 Written Records
 Electronic Records
Storage Procedures
This is necessary in order to prevent loss, theft, unauthorized access or disclosure and misuse of
information.
1. All necessary documents shall be stored securely, and only authorized personnel can have
access to records.
2. Records pertaining to the patient/client shall be kept in chronological order and shall be kept
for the minimum time required for storage of records.
3. Duplication of records should be done to ensure the physical therapist has a copy to refer to
whilst with patients/clients.
4. Records shall only be released, when appropriate, with patient’s permission.
Recording Requirements/standards
All records that are written or electronic must be collectively organized into categories depending on
the cases. It must have a signature with date by the attending member of the Kinesis Organization.
Session notes must be submitted at a maximum hour limit within the day. Periodical and progress
notes must be submitted at a maximum of 2-3 days within completion. All records must show
professional writing and legitimacy.
Retention Requirements
Medical records shall be retained for the entire period of retention as set out in the schedule. Lack of
file space and volumes of information can be ruled in if and only if assurance of patient health
information was able to meet the needs of ongoing patient care, legal requirements, research,
education, and other legitimate uses of the organization.
Confidentiality and Data Protection
All healthcare professionals must be literate enough in terms of confidentiality and data protection.
All data must be stored and kept within the medical facility and healthcare professional itself. It must
be safely stored and secured in a medical facility room and only medical staffs can enter and provide
access to sensitive information.
Access Procedures
 All healthcare professionals can gain access if and only if they wish to see the information
about a certain patient.
 The Kinesis Organization will be locked 24-hours with access granted to authorized personnel.
The Kinesis Organization hours are 7:30 AM to 4:30 PM Monday through Friday.
 The following hospital staff have keys to the Health Information Department:
- All Health Information Staffs
- Security Officers
 A patient can at any time request his / her documentation in writing to find out what
information has been submitted, by whom and how it is being used.
Disposal Requirements
Disposal of certain types of data, either written or electronic, to which includes personal and sensitive
information of the patient such as name, social security number, driver's license number, debit or
credit card number, diagnosis, treatment information, etc. may warrant more attention due to the risk
that improper disposal to such information may result in identity theft or damage to the reputation of
an individual. For written data such as in paper records, shredding, burning, pulping, or pulverizing
records in such a way that the written data is rendered essentially illegible, indecipherable, and
cannot otherwise be reconstructed. For electronic data, purging or destroying the actual electronic
device is recommended.

TOTAL: ___/35