قوانین و رویه‌های نگهداری مدارک پزشكی در کشورهای منتخب

Abstract

Background: Health records serve several purposes and must be retained to meet those purposes. These varied purposes influence how long health records must be kept, or their retention period. The present study aimed to recognize laws and procedures related to retention of health records in selected countries and provide a proposed guideline for Iran. Methods: This was an applied, descriptive-comparative research on laws and procedures related to retention of medical records in the USA, United Kingdom, Australia and Iran in 2011. The data was collected via library sources, websites, and consultation with specialists in and out of the country. The validity of the data was confirmed by experts. Finally, the recommendations were provided for medical record retention in Iran. Results: The study revealed complete and transparent record retention schedules in the selected counties. In fact, retention situations for adults, minors, emergency, outpatients and deaths records are clearly determined. However, in Iran, either no specific laws and procedures exist for medical records or they are unspecified. Conclusion: Lack of a complete, transparent and updated medical record retention schedule in Iran has led to confusion for hospitals. Some hospitals maintain medical records more than the determined retention period and some destroy them before expiring of the essential retention period. In order to optimize the situation of health records retention in Iran, it is necessary to review, correct and complete medical records retention schedule on the provided recommendations for different kinds of medical records. Keywords: Medical Records; Procedures; Legislation.