Question Details

As required by law, every health care facility must maintain a medical record 
for each patient that it treats (Pozgar, 2004). Although the exact 
specifications may vary slightly across each state, there are still some basic 
legal principles to remember when dealing with the medical record. As a part of 
the risk-management department for an assisted living facility, it has fallen to 
you to take a look at the facility- policies on medical records.
 
It is your responsibility to come up with a new policy that deals with the 
maintenance and release of medical records. 

Medical Records Policy: Part I

 
Develop Part I of the Medical Records Policy that 
focuses on the maintenance of medical records. In this section, you should 
consider things such as the following:


the contents of a medical record (i.e., what information goes in a 
record)

guidelines for properly making an entry in a medical record (i.e., how to do 
so, how to make a correction, etc.)


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