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

2. Lesson Objectives Upon completion of this lesson, students should be able to … Explain quality assurance. Discuss ownership of the medical record. Know the medical record’s statute of limitations.

3. Quality Assurance Program Goal is to improve quality of care

4. Purpose of an Incident Report Report unusual occurrence document exactly what happened goal of preventing another episode Should be completed ASAP

5. Agencies to Ensure Quality of Patient Care

6. The Joint Commission Private, nongovernmental agency guidelines to address quality of care Conducts surveys Works with facilities to correct deficiencies

7. OSHA Federal agency ensure workers safety basic safety standards fines

8. HIPAA Privacy Confidentiality

9. Study Guide (aka workbook) Evaluation of Learning ◦ Page 9 ◦ Questions 41-45 ◦ Write in book!

10. Authorizing Release of Records Physician owns the medical record Patient has the legal right to access the record a release form must be signed

11. Protected Information Substance abuse treatment records HIV/AIDS information Mental health records

12. Ownership of X-rays property of the medical facility that performed the X-rays Physicians are able to loan their films patients can buy copies

13. Patient viewing Medical Record First check with the physician or office manager for approval Never leave the patient alone with their record

14. Guidelines for Retaining Medical Records most states keep records for 2-7 years after the last treatment, The AMA recommends keeping records for 10 years

15. Post-test Page 4 study guide ◦ Answer questions 1-10 ◦ Show teacher for credit