Week 1 DQ 2 HCR 210

Week 1 DQ 2 HCR 210 - the patients medical record must be...

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Yolanda Campos HCR210 Week 1 DQ 2 Being a records management there are three ways we can maintain standards procedure. According to American Specialty Health Affiliates (ASHA) number one, entries in the medical records should be contemporaneous and made in a chronological, systematic, and organized manner. Second ways, medical records are maintained and stored in a manner which protects the safety of the records, the confidentiality of the information, and in accordance with state and federal standards. Medical records are stored away from public access and easily accessible to only authorized staff and the clinician. Medical staff will receive a written policy and training for the confidentiality of the patient information. Last but not least,
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Unformatted text preview: the patients medical record must be sufficiently complete to provide reasonable information to a subsequent health care practitioner. The daily records, at a minimum, must contain appropriate clinical documentation for each visit, including date, subjective complaints, objective findings that support the services rendered on that date, assessment of the patients status/progress, diagnostic impression, therapeutic intervention(s) provided during the visit, recommendations and instructions given to the patient, and follow-up recommendations....
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This note was uploaded on 08/25/2011 for the course HCR 210 taught by Professor Byrnes during the Spring '11 term at University of Phoenix.

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