Medical Records Policy: Part I

Develop 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 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)

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