In: Nursing
This week, we are going to examine the importance of medical records. Everyone from the top down in a hospital or medical service is responsible for accurate medical records, billing, records release and other documentation.
Please review the materials for the discussion board this week and discuss at least 2 important take-aways that you have learned about from the e-text and the materials. What are the 2 most important things? What laws underpin those things that you learned?
A medical record is an important record prepared by health care practitioners about a consultation or examination or the application of health management techniques in a single patient. It is the systematic documentation of a patient's medical history and treatment details. It includes different types of notes or prescriptions, recorded observations, and details about the application of drugs and therapies, orders for the application of drugs and therapies, tests, referral forms, lab reports, results, x-rays, and other relevant reports, etc. entered by healthcare professionals.
Medical records are very important. Medical records can be used for the following reasons:
Mainly two laws underpin the importance of medical records:
1. Health Information Technology for Economic and Clinical Health Act,2009 (HITECH Act)
Key points.
2. Health Insurance Portability and Accountability Act,1996.
Key points
In short, Good medical records are essential for the continuity of health care in patients. It also helps in defending a complaint or clinical negligence claim. A complete, up-to-date, and accurate medical record can make a good outcome for both patient and health practitioner.