Should corrections be date and time stamped? According to the American Medical Association, all medical records should be date and time stamped and should identify the corrector or the person that is making any changes of any sort. First, the individual making the correction needs to identify him or herself as having authorization to do so. Secondly, any corrections need to contain the date and time they took place so that if any questions were to arise they may be better referenced. Finally, all changes to a patient’s medical record must contain a list of people to notify of the changes. All of these steps are necessary without exception to protect the accuracy of a patient’s medical record.
When should a patient be advised of the existence of computerized databases containing medical information about the patient? A patient must understand how their medical records are being maintained. This is very important for confidentiality. Patients need to stay advised of the existence of computerized databases that contain their medical records before the records transfer to the staff entering them into the database. The patient is also to be advised as to whom will maintain their records and who will and will not have access to their medical records. Any person able to access the patient’s record through the computerized database needs to be identified to the patient before the records become part of the system. These steps are to ensure the patient that the right measures are being taken to keep their records confidential.
When should the patient be notified of the purging of archaic or inaccurate information?
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