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Whose responsibility is it to complete the medical record?
The responsibility for completing the health record rests with the attending physician and the facility administrator.
Who is responsible for the medical record?
The physical medical record actually belongs to the physician who created it and the facility in which the record was created. The information gathered within the original medical record is owned by the patient. This is why patients are allowed a COPY of their medical record, but not the original document.
Do you own your medical records?
Every patient has the right to access his medical records under federal and most state laws. The only money that can be required are the copying fees mandated by law. While keeping and transferring medical records is often routine, it's not always done properly by physician practices.
Why are medical records kept?
The most important reason for keeping a medical record is to provide information on a patient's care to other healthcare professionals. Another major rationale is that a well-documented medical record provides support for the physician's defense in the event of a medical malpractice action.
What is considered part of the medical record?
An individual's record can consist of a facility's record, outpatient diagnostic test results or therapies, pharmacy records, physician records, other care providers' records, and the patient's own personal health record. Administrative and financial documents and data may be intermingled with clinical data.
How long does a physician have to complete a medical record?
A. Yes, but not forever. Physicians and hospitals are required by state law to maintain patient records for at least six years from the date of the patient's last visit. A doctor must keep obstetrical records and records of children for at least six years or until the child reaches age 19, whichever is later.
How long do physicians have to keep medical records?
They differ on whether the records are held by private practice medical doctors or by hospitals. The length of time records is kept also depends on whether the patient is an adult or a minor. Generally, medical records are kept anywhere from five to ten years after a patient's latest treatment, discharge or death.
What is the acceptable time frame for delayed entries into a patient's medical record?
Delayed entries within a reasonable time frame (24 to 48 hours) are acceptable for purposes of clarification, error correction, the addition of information not initially available, and if certain unusual circumstances prevented the generation of the note at the time of service.
What is a complete medical record?
A medical record is considered complete if it contains sufficient information to identify the patient; support the diagnosis/condition; justify the care, treatment, and services; document the course and results of care, treatment, and services; and promote continuity of care among providers.
What is included in a complete medical record?
A medical chart is a complete record of a patient's key clinical data and medical history, such as demographics, vital signs, diagnoses, medications, treatment plans, progress notes, problems, immunization dates, allergies, radiology images, and laboratory and test results.
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