I need help in developing a medical record policy. How do you go about gathering the following information?
- The contents of a medical record (example, what information goes in a record)
- Guidelines for properly making an entry in a medical record (example, how to do so, how to make a correction, etc.)
Medical Record Policy
The medical record is a significant tool that appropriates the doctor to know about the patient's medical history and distinguish ills or patterns that may assist in deciding the way or course of health care. The key aim of the medical record is to enable doctors to serve their patients with quality health care. In other words it is a living document that describes about patient's story and aids each meeting with health professionals engaged in providing care (Appleby & Tarver, 2006). Accurate medical records also comply with all legal, regulatory, and auditing requirements. Creation of medical records is not so easy so, it is vital to have a medical record policy (Durham, 2008) that includes various aspects as discussed here.
Guidelines to gather information:
Hospital expects all doctors to keep medical records that are coherent regarding their legal duties and the prospects set out in the policy. Effective medical record-keeping is a key element of offering the ultimate quality medical care (McGuire, 2004). It is essential to do accurate and thorough documentation in the medical record and information need to be collected as per the set standards (Heller & Veach, 2008). To go about gathering information, initially it is essential that physicians obtain their patients consent in regard to collect, use, and disclose personal health information (PHI). Afterwards, the physician needs to be start medical consultation that is one of the most significant opportunities to identify patient's problems and concerns and start distinguishing the reason behind his/her ill health (Consultation, medical history and record taking, n.d.).
The three most important aspects of initiating a session need to be ...
The expert develops a medical records policy.