Why do medical records exist? Medical records are used as a reference material in medical facility.
Doctors use as much information as possible in a medical record when prescribing medicine to a patient, avoiding any complications by checking the patients’ medical record. Medical records also provide allergies, in case you’re allergic to certain medications, they’ll know not to prescribe them. They are also used in medical facilities to check vital signs such as blood pressure or pulse, if they notice any trend of abnormal signs they are quickly observed, all due to medical records existing.
Medical records also exist to offer legal protection for those provided health care. Medical records are also vital for financial reimbursement. Why is it important to maintain the medical records? Medical records should be organized in an orderly fashion, and all of the information within the record should be legible to the average reader. The information within the medical record must be accurate and corrections should be made and documented correctly. The wording in medical records should be easily understood and grammatically correct.All of these steps are important to remember when maintaining a medical record for future reference, or even legal issues. Discuss and explain the five basic filing steps. (1) Conditioning, involves removing all pens, brads and paper clips.
During this process you will also staple all related material together, and attach clippings or items smaller then page-size to a regular sheet of paper. This step is important because your starting to organize and layout the medical record. 2) Releasing, during this step a marking is placed on the papers indicating that they are ready to be filled. This step is important for other members in the medical facility dealing with the filing process. (3) Indexing and coding, this is where you decide where to file the letters or papers, and placing an indication of this decision on the paper.Every paper place in a patient’s medical record should have date and the patients name on it, usually located on the upper right corner, during this step this should be taken care of.
4) Sorting, this is where the arranging the papers in a filing sequence takes place. Papers should be sorted before they are filed and place into a patient’s medical record. Sorting allows the information inside medical records to be easily found, which is important in a busy medical facility. (5) Storing and filing, during this step items are placed face-up, top edge to the left, with the most recent date at the front of the medical record.
This is done so that the information is easily located. Part II: HIPPAExplain how HIPPA Privacy Rules benefits the healthcare industry, patient, and physician. The Privacy Rule, a Federal law, gives individual rights over your health information and sets rules and limits on who can look at and receive your health information. The Privacy Rule applies to all forms of individuals’ protected health information, whether electronic, written, or oral. The Security Rule, a Federal law that protects health information in electronic form, requires entities covered by HIPAA to ensure that electronic protected health information is secure.Health Insurers and Providers who are covered entities must comply with your right to: ask to see and get a copy of your health records ,have corrections added to your health information, receive a notice that tells you how your health information may be used and shared, decide if you want to give your permission before your health information can be used or shared for certain purposes, such as for marketing, and get a report on when and why your health information was shared for certain purpose.