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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 facilityâs 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. Your group will be developing a two-part policy for medical records. The first part will be developed individually and the second part will be developed as a group. The components of Parts I and II are laid out below.
Medical Records Policy: Part I
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 the following:
ownership of the medical record
policies/procedures for the release of records
ways to maintain confidentiality (include any major laws that govern this)