As required by law, every health care facility must maintain a medical record for each patient that it treats (Pozgar, 2004). Although the exact specifications may vary slightly across each state, there are still some basic legal principles to remember when dealing with the medical record. As a part of the risk-management department for an assisted living facility, it has fallen to you to take a look at the facility’s policies on medical records.
It is your responsibility to come up with a new policy that deals with the maintenance and release of medical records.
Medical Records Policy:
Develop Part I of the Medical Records Policy that focuses on the maintenance of medical records. In this section, you should consider things such as the following:
the contents of a medical record (i.e., what information goes in a record)
guidelines for properly making an entry in a medical record (i.e., how to do so, how to make a correction, etc.)
Medical Records Policy: Part II
Develop Part II of the Medical Records Policy. In this section, you should consider issues such as ownership of the medical record.
Medical Records: The Fundamentals
More than ever, it is critical that hospitals and other healthcare organizations have systems and procedures in place that abide by, and maintain patients’ records according to legislative laws and HIPAA guidelines. Additionally, such health records should be created, designed and maintained in an ethical, confidential and legal manner.
All entries into the medical record will be authenticated by the employee/person who made the entry. Signed and written