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b. At the time the event occurs
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∙ 14y ago
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What type of information should be included in medical charts?
Date and time should be included on all entries into the record. A person's full name and other identifiers (i.e., medical record number, date of birth) should be included on all records
What actions should be taken if you identify an error in a patients medical record?
No deletions should be made, as the medical record is also a legal document. But an amending notation should be made and added to the medical record.
Why should a recording in the medical record never be erased or abliterated?
The medical record is a legal document.
What information should be kept in a medical record?
because you would loose information.you need files to be kept or you have no proof and nothing
What should you use When indicating the exact words of a patient on a medical record?
Quotation marks should be used when indicating a patient's exact words on a medical record.
What should you do if you make an error while recording information on health care record?
When correcting an error in a medical record put a single line through it and then initial it and date it. Do not scratch it out or make it unreadable.
Will the medical record contain the method used to perform the test?
It should for proper and accurate code selection. If in doubt or if the record is missing such information, the coder must query the physician for more details.
The medical record should be released only with a?
Medical records are confidential. They should only be released after the patient has signed a release form.
How long are doctors required to keep medical records in Connecticut?
How long should a medical record be retained
If a code is not documented in medical records the medical assistant should never code a patient as having what?
a medical assistant should never code a patient as having what unless its is documented in medical record
Is it legal to destroy medical records?
Medical records are a complicated issue. Who owns them? The clinic or hospital that maintains the record, or the person about which the record is kept? Most states now say the clinic or hospital owns the actual physical record, and the person owns the information. This gives you the right to see your records and to decide who has access to them. In order to destroy the record a Judge would have to issue an order to the keeper of the record to expunge it. You would need a compelling reason as to why the record should be destroyed. It is currently not legal to have a medical record destroyed without a court order.
What happens to your medical records if you are moving to another state What is the procedure you have to take?
There is no procedure necessary, but if you want your medical record to be available to your new physician (a good idea), you should have the name and address of your physician where you are moving from so you can give that information to your new physician after the move. Your new physician can request your medical record from your old physician if you give your written permission.
