As Required By Law, Every Healthcare Facility Must Maintain

As Required By Law Every Health Care Facility Must Maintain A Medical

As required by law, every health care facility must maintain a medical record for each patient that it treats. This includes documenting all relevant health information accurately and comprehensively, such as patient demographics, medical history, treatment plans, progress notes, diagnostic test results, medication records, and discharge summaries. Proper documentation ensures continuity of care, legal protection for both the patient and the facility, and compliance with regulatory requirements such as those established by the Health Insurance Portability and Accountability Act (HIPAA), the Joint Commission standards, and state-specific laws. Records should be kept in a secure, organized manner, accessible only to authorized personnel, and maintained for the duration stipulated by law, which varies by jurisdiction.

Developing guidelines for making entries involves clear, legible handwriting or electronic documentation, using standardized formats and abbreviations, and providing timely entries after patient encounters. Corrections to entries should be made by drawing a single line through the incorrect information, annotating with the date and initials, and adding the correct information. All entries must be signed or electronically authenticated by the person making the entry to ensure accountability and traceability.

Paper For Above instruction

Part I: Maintenance of Medical Records Policy

In our assisted living facility, the maintenance of medical records is fundamental to providing quality care, ensuring legal compliance, and safeguarding patient rights. Medical records shall include all pertinent information that accurately reflects the patient's health status, treatment, and care provided. The specific contents encompass patient demographic information, physician orders, nursing notes, medication administration records, diagnostic and laboratory reports, imaging results, specialist consultations, care plans, progress notes, and discharge summaries.

The facility shall ensure that all documentation is complete, accurate, and entered in a timely manner. Entries should be made using clear, legible handwriting or through authorized electronic health record (EHR) systems with standardized templates to promote consistency and completeness. Each entry must be signed or electronically authenticated by the individual responsible for the documentation, ensuring accountability.

Proper procedures for recording information involve adhering to strict guidelines: documentation should reflect factual, objective observations; subjective data should be quoted directly from the patient or caregiver; and treatment actions must be recorded accurately, including date, time, and outcomes. Errors should not be erased; instead, they must be corrected by striking through the incorrect information with a single line, dating the correction, and initialing it, or using the audit trail features in electronic records. All modifications must be transparent for auditing purposes.

Records should be stored securely, either in locked cabinets or through encrypted digital systems that restrict access based on user roles. Backup copies of electronic records should be maintained regularly to prevent data loss. The retention period for medical records shall comply with state regulations, typically ranging from five to ten years post-discharge, depending on jurisdiction.

Part II: Ownership and Confidentiality of Medical Records Policy

Ownership of medical records refers to the legal rights and responsibilities of the healthcare facility to maintain, access, and control the information contained within the records. While the patient is the subject of the record, the facility retains ownership of the physical record or electronic database. Patients have rights to access their records, request amendments, and control disclosures in accordance with applicable laws.

To ensure confidentiality, the facility shall implement policies safeguarding patient information in compliance with laws such as HIPAA, which mandates the protection of protected health information (PHI). Access to medical records shall be limited to authorized personnel involved directly in the patient's care or with explicit patient consent. Use of electronic security measures such as passwords, user authentication, encryption, and audit logs is essential to prevent unauthorized access, breaches, or disclosures.

Any release of medical records shall follow strict procedural safeguards: verifying the identity of the requester, obtaining written patient consent when required, and maintaining a detailed log of all disclosures. The facility shall also provide training to staff regarding confidentiality obligations and legal responsibilities, ensuring adherence to privacy laws and ethical standards.

References

• Pozgar, G. D. (2004). Legal and ethical issues for health professionals. Jones & Bartlett Learning.
• U.S. Department of Health & Human Services. (2003). Summary of the HIPAA Privacy Rule. Retrieved from https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html
• The Joint Commission. (2020). Comprehensive accreditation manual for long-term care. The Joint Commission.
• American Health Information Management Association. (2021). Standards for record keeping. AHIMA Journal.
• Centers for Medicare & Medicaid Services. (2019). Medicare and Medicaid programs; reforms to strengthen oversight. Federal Register.
• National Committee on Vital and Health Statistics. (2019). Health information privacy and security. HHS Report.
• Office for Civil Rights. (2020). HIPAA Privacy Rule and your health information. HHS.gov.
• Ginter, P. M., Duncan, W. J., & Swayne, L. E. (2020). Managing health organizations and systems. Jossey-Bass.
• Schneck, C. A., & Norris, P. J. (2017). Medical records management in healthcare. Healthcare Management Review.
• Blair, P. (2018). Confidentiality in healthcare practices. Journal of Medical Ethics.