Evaluation of Unpreparedness When Issuing Copies of Medical Records in Tertiary Referral Hospitals

OBJECTIVES As a baseline study to aid in the development of proper policy, we investigated the current condition of unpreparedness of documents required when issuing copies of medical records and related factors. METHODS The study was comprised 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 admission > 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.