As required by law, every health care facility must maintain a medical record for each patient that...

Question

As required by law, every health care facility must maintain a medical record for each patient that it treats (Pozgar, XXXXXXXXXXAlthough 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. 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.

Individual Portion

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.)

Your assignment will be graded in accordance with the following criteria. Click hereto view the grading rubric.

Group Portion

Medical Records Policy: Part II

As a group, 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)

Robert · Accepted Answer

Introduction 
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.  Likewise, this particular paper throws light on 
the way how medical records are maintained at ABC Healthcare.
Medical Records Policy: Part I 
The contents of a medical record  
1. The medical record would enclose adequate information for identifying and 
assessing the patient and furnishing proof on the course of health/medical 
care of the patient. 
2. The record would involve legible and accurate documentation of any 
health division activity including or impacting the patient’s health for 
involving however not being restricted to assessment, results, tests and 
treatment.  
3. All medical records would be retained in a standard format having forms 
and entries filed in sequential manner with the highly latest on top. 
4. Every form/document filed in the medical record would contain the 
patient’s name, clinic identifier and identification number.  
5. Every entry in the medical record would include the service date, service 
description,

As required by law, every health care facility must maintain a medical record for each patient that it treats (Pozgar, XXXXXXXXXXAlthough the exact specifications may vary slightly across each state,...

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