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. 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.)
Your assignment will be graded in accordance with the following criteria. Click here to 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)
Your assignment will be graded in accordance with the following criteria. Click here to view the grading rubric.
Use the library and other outside references to look up sample policies regarding medical records to use as a guide. You may not use a policy found in your research in its entirety. This is meant to be an original policy created by you. The final product of the individual portion should be an actual policy—make sure that it is presented just as policy would be in a real assisted-living facility setting. There is no need for any explanation as to why you chose what you did.
Pozgar, G. (2004). Legal aspects of health care administration (9th ed.). Sudbury, MA: Jones and Bartlett