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Accurate Medical Records: Your Primary Line of Defense
Mark Gorney, MD, FACS, Paula A. Jenkins, Laura A. Dixon, BS, JD, RN, CPHRM, and Susan Shepard, MSN, MA, RN
It is critical for every physician to maintain meticulous records, because every medical malpractice suit can be won or lost based on the quality and content of the medical record.
Requests to Amend a Medical Record
Susan L. Marr, MSA, CPHRM
When a patient requests an amendment to the medical record, the record should contain both the patient's request and the physician's response.
Medical Record Retention
Laura A. Dixon, BS, JD, RN, CPHRM
A number of variables affect the length of time a physician should keep a medical record, such as state and federal laws, medical board and association policies, and the type of record (for example, an adult patient versus a pediatric patient record).
The Defensible Medical Record
Mark Gorney, MD, FACS, Paula A. Jenkins, and Laura A. Dixon, JD, RN
Most errors of medical judgment can be successfully defended with a complete and unaltered medical record.
Frequently Asked Questions: Medical Records Issues
Laura A. Dixon, JD, RN, and Susan Shepard, MSN, RN
Our experts answer frequently asked questions about medical records, such as length of retention, how to destroy hard copy paper records, and making backups of electronic health records.
Electronic Health Record Risks
David B. Troxel, MD, Medical Director
This discussion of EHR benefits and risks is based on articles and reports appearing in peer-reviewed and non-peer-reviewed medical literature and in the EHRevent Newsletter.
The Faintest Ink
Carol Murray, RHIA, CPHRM
Complete and timely documentation of the medical record not only enhances patient care, but it also serves to strengthen your credibility if you are called upon to defend that care.