As Required By Law, Every Healthcare Facility Must Ma 681781

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 guidelines for the contents of a medical record, proper procedures for making entries and corrections, policies on ownership of records, procedures for releasing records, and maintaining confidentiality in accordance with relevant laws such as HIPAA.

Paper For Above instruction

Maintaining accurate and comprehensive medical records is a fundamental legal obligation for healthcare facilities. These records serve as a vital part of patient care, legal documentation, and compliance with health regulations. This paper discusses the development of a hospital or assisted living facility’s medical records policy, focusing on two essential components: the maintenance of medical records and policies related to their release and confidentiality.

Part I: Policy on Maintenance of Medical Records

The contents of a medical record should encompass a wide array of information that accurately reflects the patient's health status and the care provided. Key components include patient identification data, medical history, current health status, diagnostic test results, treatment plans, medication records, progress notes, consent forms, and discharge summaries. Ensuring completeness and accuracy of these components is crucial for continuity of care and legal documentation (Pozgar, 2004).

Proper documentation practices are critical. Entries must be legible, timely, and made by authorized personnel. Every entry should clearly indicate the date, time, and the name or initials of the person making the entry. Corrections should be made by crossing out the erroneous information, initialing next to it, and recording the correct data alongside or above it, without erasing or obliterating the original entry, to preserve the record’s integrity (American Health Information Management Association, 2020).

In addition, confidentiality and security of medical records should be maintained at all times. Electronic records require password protections, encryption, and audit controls to prevent unauthorized access, while physical records should be stored in secure, restricted areas. Regular audits should be conducted to confirm compliance with these standards (Häyrinen et al., 2008).

Part II: Policies on Ownership, Release, and Confidentiality of Medical Records

The organization must clearly define ownership of medical records. Generally, while the healthcare facility physically maintains the records, the patient holds the right to access their medical information, with legal exceptions. Policies should specify that the record is the property of the healthcare provider but that patients have the right to access and obtain copies, subject to privacy regulations.

Procedures for releasing medical records must be explicit. Requests should be documented, and access should be granted only to authorized individuals or upon proper legal authority, such as a court order. When releasing records, facilities should verify requester identity, ensure only relevant information is provided, and employ confidentiality safeguards (U.S. Department of Health & Human Services, 2013).

Maintaining confidentiality involves strict adherence to laws such as the Health Insurance Portability and Accountability Act (HIPAA). This act mandates safeguards to protect patient privacy, including staff training, secure handling of records, and incident reporting for breaches. Confidentiality policies should also include guidelines on staff responsibilities, breach responses, and ongoing compliance monitoring (Snyder & Ng, 2017).

In summary, the medical records policy must comprehensively cover the management of record content, accuracy, security, ownership rights, procedures for releasing information, and confidentiality protections. This dual-part policy ensures legal compliance, protects patient rights, and promotes high standards of care.

References

• American Health Information Management Association. (2020). Coding Guidelines and Documentation Standards. AHIMA Press.
• Häyrinen, K., Saranto, K., & Nykänen, P. (2008). Definition, structure, content, use and impacts of electronic health records: a review of the research literature. International Journal of Medical Informatics, 77(5), 291-304.
• Pozgar, J. C. (2004). Legal aspects of health care administration. Jones & Bartlett Learning.
• Snyder, M., & Ng, T. (2017). Ensuring privacy and confidentiality in health information systems. Health Management Technology, 38(5), 28-29.
• U.S. Department of Health & Human Services. (2013). Health Information Privacy and Security: HIPAA Privacy Rule. HHS.gov.