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Questions & answers

Combs agrees: "The most common cause of poor documentation is a lack of understanding of the specific information that needs to be included for coding purposes.
BACKGROUND: Inaccurate and incomplete documentation can lead to poor treatment and medico-legal consequences. Studies indicate that teaching programs in this field can improve the documentation of medical records.
A problem list is a document that states the most important health problems facing a patient such as nontransitive illnesses or diseases, injuries suffered by the patient, and anything else that has affected the patient or is currently ongoing with the patient.
The short answer is most likely five to ten years after a patient's last treatment, last discharge or death. That being said, laws vary by state, and the minimum amount of time records are kept isn't uniform across the board.
A request for information from health (medical) records has to be made with the organisation that holds your health records \u2013 the data controller. For example, your GP practice, optician or dentist. For hospital health records, contact the records manager or patient services manager at the relevant hospital trust.
Your last GP in the UK will be able to tell you how to contact them. GP records will be stored for 10 years. Hospital records will be stored for eight years.
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