American Intercontinental University
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, ...view middle of the document...
It also requires for a follow-up care plan to be noted in the discharge summary.
Guidelines for Properly Making an Entry in a Medical Record
So that staff can make entries properly in a medical record is important to make sure that correct chart is being used. Information must be written legibly in black or other dark ink and data should be brief but complete. Each page of the medical record needs to have the patient’s name and identification number. Every time an entry is being made, the person must sign or initial the new records added. In addition, Staff is expected to use proper grammar in all medical terms and to only use abbreviations that are known by the general staff when documenting records. It is important for everyone in organization to understand that nobody is allowed to remove any information from medical records in any way. Moreover, staff must document only relevant information about the patient, staff is not write their personal opinions, speculations, judgments or any other information that is irrelevant to patients and their care.
When errors occur...