Chp 1Chp 1Managing Medical Managing Medical RecordsRecordsLesson 3:Lesson 3:Releasing, Retaining, and Storing Releasing, Retaining, and Storing Medical RecordsMedical Records

Quality Assurance ProgramQuality Assurance Program

Goal is to improve quality of care

Purpose of an Incident ReportPurpose of an Incident Report

Report unusual occurrence

document exactly what happened

goal of preventing another episode

Should be completed ASAP

The Joint CommissionThe Joint Commission

Private, nongovernmental agency

guidelines to address quality of care

Conducts surveysWorks with facilities to correct deficiencies

OSHAOSHAFederal agencyensure workers safetybasic safety standards

fines

Study Guide (aka Study Guide (aka workbook)workbook)Evaluation of Learning

◦Page 9◦Questions 41-45◦Write in book!

Authorizing Release of RecordsAuthorizing Release of Records

Physician owns the medical record

Patient has the legal right to access the record

a release form must be signed

Protected InformationProtected Information

Substance abuse treatment records

HIV/AIDS informationMental health records

Ownership of X-raysOwnership of X-raysproperty of the medical facility

that performed the X-rays Physicians are able to loan

their filmspatients can buy copies

Patient viewing Medical RecordPatient viewing Medical Record

First check with the physician or office manager for approval

Never leave the patient alone with their record

Guidelines for Retaining Medical Guidelines for Retaining Medical RecordsRecordsmost states keep records for 2-7

years after the last treatment, The AMA recommends keeping

records for 10 years