Chapter 6: Recordkeeping
Reasons for Recordkeeping
It’s hard to imagine a profession where there is more emphasis placed on documentation than medical laboratory technology. We record everything from personal information to characteristics of the specimen received, minute steps in specimen processing and analysis, quality control, and details of reporting. We do all this to:
- Record relevant contact and health information
- Facilitate collaboration between technologists who share the work on a specimen
- Allow reference to other specimens from the same patient
- Ensure appropriate specimen handling and accurate results
- Facilitate troubleshooting and problem solving for methods and equipment
- Document information that might be needed later, or by other health care professionals
- Compile data for statistical, funding, and cost analysis, and research
- Comply with legal and accreditation requirements
- Continuously improve our procedures
- Support accountability and risk management
Good record keeping is important for many reasons, and current digital laboratory information systems make it easier than ever to keep and access good records.
What Should be Recorded?
We record both relevant personal health information, and information about our analysis of clinical specimens.
Personal Health Information
With respect to the personal health information of individuals, the Personal Health Information Act requires that we keep only as much information as we need. This may differ from one institution or business to another and is dictated by circumstances. The MLT employed by someone else need only follow employer protocol when considering what information to collect and record.
The self-employed MLT should refer to relevant legislation and business requirements, with his or her own particular business arrangement in mind.
SCENARIO:
Josef is starting up a private blood collection service for people with mobility challenges. As phone calls start coming in, he wonders what information he should be collecting from his clients. Name, address and phone number are a must. Any special information such as whether it is a fasting sample, and whether other specimen collection containers are required should also be recorded, along with special instructions from the client, and later, notes that will help if the client calls again.
He’ll need to retain a record of what tubes he collects, and if he hires anyone to help him, he’ll need to keep a record of who took the blood. Josef knows he’ll need to ensure that all the information the lab needs is on the requisition, but he can’t decide whether he needs to make a copy for his own files.
Josef does need to keep enough information to respond to questions about the samples if any arise; however, he does not need a copy of the requisition to answer those questions. Furthermore, he should not retain a copy of the requisition because it contains personal information, such as date of birth, health card number, and possibly health details that should not be in his possession. Similarly, he should not ask irrelevant questions of his clients – Josef must collect only the information that he needs to provide the service.
Laboratory Data
A second category of record keeping involves documenting everything we do with a patient sample once we receive it in the lab. We record activity and the results of tests on each specimen as we work, and this information becomes part of the permanent record of the specimen.
This detailed record keeping of laboratory data is important because it allows us to verify who did the work, and that everything was done correctly. It provides us with a record of workload so that we know the cost of dealing with the specimen from beginning to end. Perhaps most importantly on a day-to-day basis, it ensures continuity from one technologist to another if extra tests or the whole specimen must be handed off to someone else. Because we are so good at recording our work for others to follow, sample results will be the same, regardless of whether one person or three different people worked on that sample.
Terminating or Selling Your Business
If you close down your private business, you can’t just pitch all your records into the nearest trash can and walk away. Those records should be safely maintained to meet the requirements of the relevant legislation. Revenue Canada requires businesses to keep records for a minimum of six years, and personal health information should be kept for at least ten (see Disposal of Records, below). It’s your responsibility to ensure that records containing personal health information are held securely and disposed of appropriately, in a timely fashion. Patient confidentiality must be maintained at all times.
Alternatively, you might sell your business and pass at least some of the records along to a new “custodian.”
SCENARIO:
Josef’s private blood collection service is doing well and his list of clients is growing, but family obligations and the long hours don’t work well together. He decides to sell. The value of his company lies primarily in his client and contact list, but this is private and confidential personal information. Is it okay for Josef to sell this information and how much of it can he allow to pass into other hands?
Josef would be wise to obtain the consent of his clients before passing along any personal information to the new business owner. Many clients will be happy to know that they can still have their blood taken at home, but others might resent having their
contact information sold to a stranger. Although the new owner will be running the same company and providing the same service, Josef has developed a relationship with his clients and he can’t assume that they’ll be happy to start over again with the new owner.
If Josef has been observing the requirements of the Personal Health Information Act, he won’t be at risk of sharing information the new owner doesn’t need. Most information Josef has retained about his clients would have been collected with their implied informed consent; however, it might go beyond simple contact information. For example, he might have a note about Lavinia Edwards that she tends to feel faint, or that her cat bites! This information would be useful to the new owner in making a seamless transition, but Josef can’t be sure Ms. Edwards wants the information shared. Again, he’d be wise to obtain consent.
If you are a business owner like Josef, you are the custodian of the personal health information in your possession. If you sell your business and agree to provide the new business owner with a client list, you must make sure that you provide only the minimum information that the new owner requires, and he or she must agree to become the custodian of the information. Patient confidentiality must always be respected. As in all activities, the security of the information must be protected during the transfer from one custodian to another.
Disposal of Records
Laboratories generate a great deal of documentation that contains personal health information. Much of it is kept for various periods of time, but much is used only briefly and then discarded. Whenever you are disposing of anything that contains personal health information, it must be discarded in such a way that it cannot fall into the hands of anyone not authorized to see it. This means that it has to be destroyed to the extent that it cannot be put back together and read.
All employers who are custodians of personal health information are required to document reasons for retaining information, and have a schedule for disposing of it. Employer protocol will also dictate the final means of destruction— normally shredding of paper documents and irreversible erasure of electronic files, including backup copies. The responsibility of the employed MLT is to diligently follow the employer’s protocol for disposing of sensitive information.
In Nova Scotia, patient files are retained by physicians for ten years after the last encounter with the patient, or ten years past the age of majority (19). Accreditation standards and employer protocol may also serve as a guide for determining when it’s appropriate to dispose of records.
Conclusion
Good record keeping is important for many reasons ranging from continuity of excellent care to data to support funding. Medical laboratory professionals are particularly good at keeping records of the work they do to ensure that nothing is overlooked and there is something for others to refer to.
Once the information is no longer needed, however, it should be disposed of. In Nova Scotia, legislation dictates what personal health information we can collect, and requires that we have an effective schedule and process for disposing of it appropriately.
Consent to the collection of personal health information, and our duty of confidentiality are closely related to recordkeeping practices.
