Highlights
Improper medical records can subject health care practitioners to civil and criminal liability.
Medical records must meet federal standards for documentation.
Even informal medical encounters should be documented.
Patient confidentiality must be respected when releasing medical records.
Medical records must never be altered or fabricated.
Introduction
A Historical Perspective
Legal Uses Of Medical Records
Medical Malpractice Litigation
Medical Records as a Plaintiff's Weapon
Defensible Records
Administrative Review of Records
Criminal Discovery
Quality Assurance and Accreditation Review of Records
Medical Office And Clinic Records
Basic Patient Information
Team and Managed Care
Maintaining the Records
Readability
Altered Records
Protecting Records
Retention of Records
Statutory Requirements on Recordkeeping
Destroying Records
Telephone Encounters
Off-Chart Records
Releasing Medical Records
Authorizing Release of Medical Information
Preventing Unauthorized Release
Selling Medical Records
Pediatric Records
Acute Illness Observation Scale
Recording Physical Growth and Development
Recording Neuromuscular Development
Hospital Medical Records
Electronic Medical Records
References
Suggested Readings
Exhibit 7-1 - P.L. Mccarthy's Technique For Evaluating Pediatric Patients
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