Locate Chart Release

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How to Locate Chart Release

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Chart locator system. Is designed to track the paper medical record. Joint commission. Regulations require medical records be readily accessible for patient care.
Medical record. ... The medical record includes a variety of types of “notes” entered over time by health care professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, x-rays, reports, etc.
Your medical records contain the basics, like your name and your date of birth. ... Your records also have the results of medical tests, treatments, medicines, and any notes doctors make about you and your health. Medical records aren't only about your physical health. They also include mental health care.
Authorized clinicians, as well as laboratory personnel, specialists and other medical professionals access these records. These records follow you throughout your life.
Medical Records Deficiency Reporting System. Brief Description. MED REC/PLUS (Med data) is an automated incomplete chart management program. It is used to define patient chart deficiencies for Discharge Summaries and Notes for JHH providers, and generate a variety of reports in both text and graphic format.
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.
The Chart Deficiency module provides the Health Information Management department with a system to track all activity required to complete a patient's chart. Once a chart is returned to the department, it is collated, sorted and analyzed to determine if any deficiencies exist.
Altered Medical Records Defined It is considered malpractice to make false or unauthorized changes to any patient's medical records as doing so relates to patient treatment. When this occurs, the party may have a valid medical malpractice claim.
The goal of the thinning guideline is to retain documentation in the resident's chart that reflects the current plan of care and services provided, as well as maintaining a record of manageable size for use by the care providers.
Clinical/Medical/Infection Control Records 5 years after discharge of an adult patient. If the patient is a minor when discharged, the facility shall ensure that the records are kept on file until his or her 19th birthday and then for an additional 5 years.
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