Evaluation of unpreparedness when issuing copies of medical records in tertiary referral hospitals

Abstract

Objectives: As a baseline study to aid in the development of proper policy, we investigated the current condition of unpre-paredness of documents required when issuing copies of medical records and related factors. Methods: The study was com-prised of 7, 203 cases in which copies of medical records were issued from July 1st, 2007 through June 30th, 2008 to 5 tertiary referral hospitals. Data from these hospitals was collected using their established electronic databases and included study variables such as unpreparedness of the required documents as a dependent variable and putative covariates. Results: The rate of unpreparedness of required documents was 14.9%. Multiple logistic regression analysis revealed the following factors as being related to the high rate of unpreparedness: patient age (older patients had a higher rate), issuance channels (on ad-mission > via out-patient clinic), type of applicant (others such as family members > for oneself > insurers), type of original medical record (utilization records on admission > other records), issuance purpose (for providing insurer > medical use), residential area of applicant (Seoul > Honam province and Jeju), and number of copied documents (more documents gave a lower rate). The rate of unpreparedness differed significantly among the hospitals; suggesting that they may have followed their own conventional protocols rather than legal procedures in some cases. Conclusions: The study results showed that the level of compliance to the required legal procedure was high, but that problems occurred in assuring the safety of the medical information. A proper legislative approach is therefore required to balance the security of and access to medical information. © 2010 The Korean Society of Medical Informatics.