Medical Records Policy: Part IDevelop Part I of the Medical Records Policy that focuses on the maintenance of medical records. In this section you should consider things such as the following:
the contents of a medical record (i.e. what information goes in a record)
guidelines for properly making an entry in a medical record (i.e. how to do so how to make a correction etc.)
Medical Records Policy: Part II
develop Part II of the Medical Records Policy. In this section you should consider issues such as the following:
ownership of the medical record
policies/procedures for the release of records
ways to maintain confidentiality (include any major laws that govern this)