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

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.

Quality Assurance Program Goal is to improve quality of care

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

Agencies to Ensure Quality of Patient Care

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

OSHA Federal agency ensure workers safety basic safety standards fines

HIPAA Privacy Confidentiality

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

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

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

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

Patient 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 Records most states keep records for 2-7 years after the last treatment, The AMA recommends keeping records for 10 years

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