Medical Records

Some things are.....

Patient's demographics.

Diagnosis.

Treatment.

Previous history.

Doctors Notes.

It depends on where you are.

Heres a list of how long different records should be kept. I think this is in the UK

Technical safeguards

The medical records tech works in the medical records dept and pulls and files the records.

A medical coder reviews doctor's notes and other records and translates them into numerical diagnosis and procedure codes, usually for the purpose of billing insurance companies.

A coder is a much more trained individual.

consent release form.

Technical Safeguards

technical safeguards

At the fedreal level in the US, this would be the Health Insurance Portability and Accountability Act (HIPAA) aka the Kennedy/Kausebaum act.

Incident reports are for hospitals to track errors and prevent them in the future. They are purposely not meant to be punitive, because this would prevent employees from filing them. If an incident report is placed in a medical record it becomes potential evidence should a patient file a lawsuit. Likewise, if an incident report is even MENTIONED in a medical record as being filed, it is discoverable by an attorney and can be used in a lawsuit.

ap supine

Yes, and typically providers just ask the patient if it's OK to let family members know health information. HIPAA does not require a written consent from the patient to release information to others, even if they are not next of kin.

Technical safeguards

almost always your doctor. they use a 3rd party company that contacts the doctor and pulls your medical files and gives them to the company to review. they also can run an electronic MIB report that pulls basic info such as doctor visit frequency, surgeries, major conditions, etc.

when you sign the application there is a statment or often a separate signature page that is a waiver to give them permission to access your records. so basically they have complete legal rights to obtain your records. but they are also bound by privacy laws and cant disclose this info to anyone, not even the agent that sold you the policy get to see the full records.

Whether in a war zone, a major city hospital, or a small-town urgent care, triage nurses perform the same basic duties. They assess the patient's vital signs and needs, and assigns to that patient a determination of "level of care". In a war-zone or E.R., this means determining which patients have a higher priority than another patient. An obvious example would be a wound that pumps arterial blood is more urgent than a sprained ankle. A less obvious example would be recognizing that a drowsy patient with changes in vital signs after a seemingly minor fall could have a head injury, versus someone who cut a foot on glass and the wound has stopped bleeding.

Triage nurses can deliver nursing care, if short-staffed. But typically during the shift that the nurse works in triage, he or she would only do assessments, prioritizing patients, and routing patients in order of need and level of care. In a war zone this means knowing that a patient with a closed head injury or open compound fracture likely will need surgery; or knowing which patients need immediate infusions of fluid or blood, versus those less critical or less in need of primary support (medical-nursing actions that support life).

Yes, Tennessee law requires healthcare providers to retain medical records for a minimum of ten years from the date of last treatment for adult patients and for ten years after a minor reaches the age of majority (18 years old).

yes

I think its a stone tablet.. Pre historic times doesnt have papers until Babylonian time..

Cna

All medical records are legal documents and are to be kept from the time you are born, when you switch Dr.'s, and even after your death for a minimum of five years. Some Dr.'s still like to play it safe, and will move you health records to an electronical disk, and will keep it in storage off premises away from his or her office for safe keeping. Eventually they will be burned.

**Legally your health record belongs to the Dr. and you, which means you have the legal right to obtain a copy of your record. If they don't have it or missed placed it you could have a legal matter on your hands.

why is medication given at set intervals

in Michigan for standard dr offices its 7 years... I believe hosp's keep em for 30 years

VinStrat