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Administrative (Non-Clinical) Policy
UWHC only (Hospital Administrative-entity wide) UWMF only (entity wide)
UWHC Departmental (indicate name) UWMF Departmental (indicate name)
UWHC and UWMF (shared)
Policy Title: Security of Paper Medical Records
Policy Number: 6.21
Effective Date: May 1, 2015
Chapter: Medical Records
To establish guidelines for the security of paper medical record information maintained at the University
of Wisconsin Hospital and Clinics. (See Hospital Administrative Policy 4.39-Electronic Medical Record
Audit policy for security of computerized medical records).
The physical security of all medical records, including approved subcharts, will be ensured by the
presence of hospital personnel at all times. When personal observation is not possible, the medical records
will be removed and placed in a secure or locked area as appropriate.
A. All medical records, inpatient and outpatient, are the property of the Hospital and will be made
available for patient care, peer review, legal, or other legitimate Hospital purposes.
B. Health Information Management (HIM) is the custodian of the medical record. HIM should
always be consulted before the original medical record is removed from the hospital. Whenever a
subpoena or court order for records is received, it should be referred to HIM to arrange the
C. The medical record will be attended by hospital personnel at all times to ensure the integrity and
confidential nature of patient information. Medical records should not be given to patients to
transport between clinic appointments. (Health Information Management should be contacted to
make arrangements for delivery of records to offsite locations).
D. Hospital personnel are instructed to secure the medical record when the area is to be unattended.
1. On inpatient units and clinics, medical records are to be stored in designated areas,
including work and dictation rooms, and when unattended, doors to the area shall be
2. In all other areas, the medical record is to be placed in a locked cabinet or the room
where records are located is to be locked.
3. Chart location will be noted in the chart tracking system or by direct contact with the
Health Information Management Department.
4. A change in chart location should be relayed to HIM by calling 203-4605.
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5. The identification of individuals with access to locked areas in which charts are secured
will be provided to the Health Information Management Department.
E. Employees who are also UWHC patients should not order their own or family members' medical
records. Viewing of such records must be scheduled with the Health Information Management
Department (see Hospital Administrative Policy 6.13-Patient Right to Access Their Medical
F. The medical records shall be kept in a secure location with consideration for protection against
damage by water, fire and smoke.
Sr. Management Sponsor: VP, Chief Information Officer
Author: Director, Health Information Management
Reviewer: Medical Records Committee
Approval Committee(s): Administrative Policy & Procedure Committee; Medical Board
President & CEO
Previous revision: 052012
Next revision: 052018