Medical Records Management SOP Template

1.Purpose

To keep patient records complete, accurate, secure and available to authorized staff, while releasing information only to properly verified and authorized requesters.

2.Scope

Applies to the management of paper and electronic patient records, including release of information requests. Clinical documentation content standards are covered by separate department SOPs.

Definitions

Release of information (ROI)

A request from a patient, provider or third party for a copy of some or all of a patient's medical record.

Authorization form

A signed document from the patient or their legal representative permitting release of specific records to a named recipient.

Retention schedule

The facility's documented policy for how long different types of records must be kept before they can be destroyed.

Chart deficiency

A missing signature, order or required entry that must be completed before a record is considered complete.

3.Responsibilities

Health Information Clerk

Files and scans records, tracks chart deficiencies and processes routine release of information requests.

Health Information Manager

Oversees the department, approves complex or sensitive release requests, and manages the retention schedule.

Provider

Completes and signs documentation and clears assigned chart deficiencies within the required timeframe.

Privacy Officer

Reviews unusual or disputed release requests and investigates any suspected privacy breach.

RACI matrix

R = Responsible, A = Accountable, C = Consulted, I = Informed

4.Materials and PPE

Materials, tools and systems

• →EHR and document management system
• →Chart deficiency tracking report
• →Release of information authorization forms
• →Retention schedule policy document
• →Secure shredding or destruction service log
• →Photo ID verification process for in-person requests

5.Procedure

1. 5.1

   Scan and file incoming documents

   Health Information Clerk

   Scan paper documents and file them into the correct patient record in the document management system within the timeframe set by department policy.

2. 5.2

   Run the chart deficiency report

   Health Information Clerk

   Run the deficiency report on the schedule set by the department, identifying missing signatures, orders or required entries by provider.

3. 5.3

   Notify providers of deficiencies

   Health Information Clerk

   Send deficiency notices to the responsible provider with a due date, and escalate to the medical staff office for repeated overdue deficiencies.

4. 5.4

   Complete assigned deficiencies

   Provider

   Review and complete assigned chart deficiencies, such as missing signatures or dictated notes, within the timeframe required by facility policy.

   Checkpoint: Charts are marked complete only after every required signature and entry is present.

5. 5.5

   Receive a release of information request

   Health Information Clerk

   Log the incoming request, whether from the patient, another provider or a third party, and identify the specific records and date range requested.

6. 5.6

   Verify the requester's identity and authority

   Health Information Clerk

   Confirm the requester's identity with photo ID or an equivalent verification method, and confirm they are legally entitled to receive the records requested.

   Checkpoint: Requester identity and legal authority are verified before any record is released.

7. 5.7

   Confirm a valid authorization

   Health Information Clerk

   Check that the signed authorization form covers the specific records, date range and recipient requested, and that it has not expired.

   Warning: Never release records based on a verbal request alone or an authorization form that does not match the request.

8. 5.8

   Escalate sensitive or unclear requests

   Health Information Manager

   Route requests involving sensitive record categories, minors, deceased patients or legal disputes to the health information manager or privacy officer for review before release.

9. 5.9

   Compile and release the records

   Health Information Clerk

   Compile only the records covered by the authorization, redact any information outside its scope, and send them through an approved secure method.

10. 5.10

    Log the disclosure

    Health Information Clerk

    Record what was released, to whom, when and by what method in the disclosure tracking log required for accounting of disclosures.

11. 5.11

    Apply the retention schedule

    Health Information Manager

    Review records approaching the end of their retention period against the facility's retention schedule before scheduling destruction.

12. 5.12

    Destroy records securely

    Health Information Manager

    Destroy eligible records using an approved secure method, such as shredding or certified electronic destruction, and log the destruction with date and method.

6.Quality checks

• →Chart deficiency rate stays below the facility's target for overdue items.
• →Every release of information request has a verified requester identity on file.
• →Disclosure log entries match the volume of processed release requests.
• →No record is destroyed before its retention period has expired.

7.Records

• →Chart deficiency tracking report
• →Release of information authorization forms
• →Accounting of disclosures log
• →Record destruction log

8.KPIs

• →Average chart deficiency completion time
• →Release of information turnaround time
• →Percentage of requests verified before release
• →Records destroyed on schedule versus overdue

9.Common mistakes

• →Releasing records based on a phone request without written authorization.
• →Filing a document into the wrong patient's record.
• →Letting chart deficiencies go untracked past the required completion window.
• →Destroying records without checking the retention schedule first.

10.Revision history