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.
Medical Records Policy:
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.)
Medical Records Policy: Part II
Develop Part II of the Medical Records Policy. In this section, you should consider issues such as ownership of the medical record.
Medical Records: The Fundamentals
More than ever, it is critical that hospitals and other healthcare organizations have systems and procedures in place that abide by, and maintain patients' records according to legislative laws and HIPAA guidelines. Additionally, such health records should be created, designed and maintained in an ethical, confidential and legal manner.
All entries into the medical record will be authenticated by the employee/person who made the entry. Signed and written signatures and in some case even initials, electronic signatures, and computer-generated e-type signature codes are also acceptable as authentication. The medical record entries will also include all observations, concerns, queries, notes, and orders etc., made by care providers in a relationship with the patient/resident, and others who are authorized to do so. Finally, all signatures and/or initials, written, electronic, or computer-generated, shall include the initials of the signer's credentials (JCAR, n.d.). As such, as a part of the risk-management department for an assisted living facility it would be critical that the following contents be included but not limited to part I of the facility's patients' medical records policy.
Medical Records Policy: Part 1
The Patient Profile should contain demographic information such as: The current date; Name(firs, middle, and surname); Phone number; Gender; Address; Age; Marital status , Place and Date of birth; Education and Occupation; Current weight(any recent loss or gain in weight), as well as:
• Health insurance information
• Current medications and treatments
• Next of kin and emergency contacts(home and cell phone numbers)
• Illnesses and surgeries(if any) allergies to medication (if any)
• List of current doctors and their contact information
• What patients are currently being treated for
• Any current stressors or major life altering circumstances?
• Family medical history, especially anything that patient could be predisposed to (i.e. breast cancer, heart disease, diabetes).
• Date of last annual physical
• Age of first Menstruation and history(if applicable)
• Age of onset of menopause and history (if applicable)
• Cognitive information-Is patient's memory (and all other senses intact) (seems coherent)?
• Is patient sexually active-and if so, do they practice safe sex?
• Do they have kids-How many? Any history of sexual or physical abuse
• Sleep patterns, any major complaint, and history of the complaint
• Lifestyle choices, how they eat, do they drink or smoke, and if so how often?
• Do they exercise, and if so how often?
• Past hospitalizations; recent losses; changes in marital status etc.,
• Bowel patterns:(recent movement and any significant changes)
• (If/where/when applicable) Results of initial examination should be recorded and should include blood pressure measurement, weight, height, and visual /eye ...
The ethical and legal issues in healthcare are examined. The facilities policies on medical records are determined.