A patient’s medical record is to remain safely kept and private from anyone who does not have access to it. In order for a health care organization to keep a patient’s medical records safe, it is important that the have rules, safety policies, procedures, and training in place for their employees. This rule gives employees knowledge regarding medical records. The first part of the rule states that a record must exist for every patient that receives care in the hospital because if there is not a medical record for a patient, care should not be given to the patient until a medical record is created. This rule also gives the standards for what should be included in a patient’s medical record. Why is the patient being seen, what day and time did the patient receive care, what was the patient’s complaint? Basically, any information that happens within the time that the patient is receiving care should be documented for the medical record to remain legible. This rule applies to all departments within the hospital ranging admission of a patient to receiving care from a doctor to x-rays or bloods tests to the patient being discharged. All of the information within that time needs to be documented to a patient’s medical record. Medical staff should never do anything without properly documenting what they are doing in a medical workplace. I read about the administrative law in the text book this term, however, now having the knowledge to find these rules whenever I have a question in my head while working in a health care organization will greatly benefit me in times of
A patient’s medical record is to remain safely kept and private from anyone who does not have access to it. In order for a health care organization to keep a patient’s medical records safe, it is important that the have rules, safety policies, procedures, and training in place for their employees. This rule gives employees knowledge regarding medical records. The first part of the rule states that a record must exist for every patient that receives care in the hospital because if there is not a medical record for a patient, care should not be given to the patient until a medical record is created. This rule also gives the standards for what should be included in a patient’s medical record. Why is the patient being seen, what day and time did the patient receive care, what was the patient’s complaint? Basically, any information that happens within the time that the patient is receiving care should be documented for the medical record to remain legible. This rule applies to all departments within the hospital ranging admission of a patient to receiving care from a doctor to x-rays or bloods tests to the patient being discharged. All of the information within that time needs to be documented to a patient’s medical record. Medical staff should never do anything without properly documenting what they are doing in a medical workplace. I read about the administrative law in the text book this term, however, now having the knowledge to find these rules whenever I have a question in my head while working in a health care organization will greatly benefit me in times of