Guideline for Medical Records

Legal checkup Record Standards Policy No. 9420 judicial MEDICAL RECORD STANDARDS PURPOSE To establish guidelines for the contents, maintenance, and confidentiality of patient health check Records that meet the requirements set forth in federal and maintain laws and regulations, and to define the portion of an individuals health make out information, whether in paper or electronic format, that comprises the medical checkup mark. Patient medical information is contained within multiple electronic playscripts systems in conclave with financial and other types of information. This policy defines requirements for those components of information that comprise a patients complete Legal medical checkup Record. DEFINITIONS aesculapian Record: The collection of information concerning a patient and his or her health care that is created and maintained in the regular configuration of UC__ business in accordance with UC__ policies, made by a person who has knowledge of the acts, events, opinions or diagnoses relating to the patient, and made at or around the time indicated in the documentation. The medical record may include records maintained in an electronic medical / record system, e.g., an electronic system framework that integrates data from multiple sources, captures data at the point of care, and deems caregiver decision making.

The medical record excludes health records that are not official business records of UC, much(prenominal) as personal health records managed by the patient. Each Medical Record shall contain sufficient, accurate information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers. The information may be from all source and in any format, including, but not limit to print medium, audio/visual recording, and/or electronic display. The Medical Record may also be known as the Legal Medical Record or LMR in that it serves as the documentation of the healthcare services provided to a... If you want to get a full essay, order it on our website: Ordercustompaper.com

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