Ethics and Legal

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’s 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.  . The components of Parts I and II are laid out below.

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.)

Develop Part II of the Medical Records Policy.  

• ownership of the medical record (only this bullet)
• policies/procedures for the release of records (do not do)
• ways to maintain confidentiality (include any major laws that govern this)(do not do)

Guidelines

Look up sample policies regarding medical records to use as a guide. You may not use a policy found in your research in its entirety. This is meant to be an original policy created by you. The final product of the individual portion should be an actual policy—make sure that it is presented just as policy would be in a real assisted-living facility setting. There is no need for any explanation as to why you chose what you did.