Topic > Information management: the medical record as a legal document...

So that hospitals and other healthcare facilities can prevent the thousands of deaths and injuries that occur every year due to medical errors; health systems have been required to implement new record-keeping technologies. This technology made patient information and care accessible to all who needed to see it. This is especially important when a patient has more than one treating doctor and their care relies on each doctor knowing what the other has done, serving as the primary communication tool between doctors. If organizations do not centralize their technology and essentially their patient databases, the risk of duplication of work or inefficient patient care can increase exponentially. These high-tech medical records can help protect both doctors and hospitals from any lawsuits that may be filed on behalf of their patients. By correctly and accurately documenting all symptoms, illnesses, treatments, medication dosages, and diagnoses, the doctor and healthcare providers can effectively demonstrate what actions have been taken with the patient, communicate with third-party billers, and even use the information collected for educational purposes. Keeping accurate records of a patient's medical care makes a big difference in many aspects of healthcare; especially when a tort or negligence claim is filed against the hospital and/or a doctor. Hospitals are required to keep a record for each patient in accordance with the professional standards accepted by the hospital. Each state has laws that contain certain requirements that each organization must meet within the established standards. These records should be maintained daily, if not more often, and should contain all pertinent information regarding... half of the document... extracted from http://www.medleague.com/ Services/medical_records/detecting_tampering.htmDebusmann, B. (2011, February 8). Most Americans Prefer Electronic Health Records: Study. Retrieved from http://www.reuters.com/articles/2011/02/08/us-records-electronic-idUSTRE7174QS20110208Jethani,J. (2004). Medical record: its importance and the relevant legislation. Vision 2020, IV(1), Retrieved from http://laico.org/v2020resource/files/medical_records_Jan>mar04.pdfKasprak,J. (2006, January 9). Patient access to medical records. Retrieved from http://www.cga.ct.gov/2006/rpt/2006-R-0599.htm Knowlton, S. (2003, April), Medical Record: Treatment Tool or Litigation Device? Retrieved from http://www.findarticles.com/p/articles/mi_qa3977//is_200303/ai_n9216533Pozgar, GD (2007) Legal aspects of healthcare administration. (10th ed.). Mississauga, Canada: Jones and Bartlett