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HOSPITAL MEDICAL RECORDS

Each hospital has its own rules for maintaining medical records; most of these derive from the standards set by the JCAHO, which provide a detailed guide to keeping records. Relevant sections of the Hospital Accreditation Manual are reproduced in the chapter appendix because every physician who practices in an accredited hospital should be familiar with its requirements for medical records management. As plaintiffs' attorneys become more sophisticated, it is increasingly likely that physicians accused of poor record-keeping practices will be examined in court on these standards.


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