Health Care Medical Record Policies

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. will be developing a two-part policy for medical records. The
components of Parts I and II are laid out below.

APA
Format 3 pages

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. Clickhereto view the grading rubric.

Medical
Records Policy: Part II

Develop in 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. Clickhereto view the grading rubric.

Guidelines

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.

Explanation & Answer

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