Power Point Ip3

Individual Project

American Intercontinental University

3/29/2014

Dr. Miller

Introduction

Medical records are legal documents that contain vital information about the patient and his/her health. By law, each healthcare facility must create and maintain records for each and one of their patients. Specifications are slightly different across each state, but there are basic standardized procedures to handle health information appropriately.

Contents of the Medical Record

Medical records contain medical and personal information about a patient. Clinical notations developed by the physicians providing care for the patients are also found in medical records. The patients address, full name, marital status, date of birth, employer, and insurance information is some of the personal information gathered for entry in medical records. The medical data consist of all record of medical checkups, including laboratory results, consent forms, and x-rays (Fremgen, 2012). Correspondences such as letter of withdraw or consultations report from other physicians will be added to medical records as well. Any consent provided by the patient after adequate explanations of treatments and procedures will be documented in the patient’s medical record.

Because medical records can be used in court by the physician or patients as evidence in case of a law-suit, some states have passed statutes to define what information must be enclosed in a record. Based on the requirements for accreditations of Joint Commission on Accreditation of Healthcare Organizations (JCAHO), these statutes are to be given as a minimum standard for the content of a medical file (Fremgen, 2012). They are as follows: preliminary diagnosis, evidence of examination from physician that includes health history and is not more than 48 hours after admission or seven days before admission to hospital. Any complications like adverse side effects to medications or infections acquired at the facility must also be...