Health Insurance Portability and Accountability Act and Medical Records

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Unit 7 Project Parts I & II
Medical Office Management HS210-03
Kaplan University

Unit 7 Project Parts I & II
Part I: Filing Medical Records
Why do medical records exist? Medical records are used as a reference material in medical facility. Doctors use as much information as possible in a medical record when prescribing medicine to a patient, avoiding any complications by checking the patients’ medical record. Medical records also provide allergies, in case you're allergic to certain medications, they'll know not to prescribe them. They are also used in medical facilities to check vital signs such as blood pressure or pulse, if they notice any trend of abnormal signs they are quickly observed, all due to medical records existing. Medical records also exist to offer legal protection for those provided health care. Medical records are also vital for financial reimbursement. Why is it important to maintain the medical records? Medical records should be organized in an orderly fashion, and all of the information within the record should be legible to the average reader. The information within the medical record must be accurate and corrections should be made and documented correctly. The wording in medical records should be easily understood and grammatically correct. All of these steps are important to remember when maintaining a medical record for future reference, or even legal issues. Discuss and explain the five basic filing steps. (1) Conditioning, involves removing all pens, brads and paper clips. During this process you will also staple all related material together, and attach clippings or items smaller then page-size to a regular sheet of paper. This step is important because your starting to organize and layout the medical record. (2) Releasing, during this step a marking is placed on the papers indicating that they are ready to be filled. This step is important for other members in the medical facility dealing with the filing process. (3)...
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