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1Ms. McNary is a Senior Risk Manager at PRMS, Inc.
Abstract:
This ongoing column is dedicated to providing information to our readers on managing legal risks associated with medical practice. We invite questions from our readers. The answers are provided by PRMS, Inc. (www.prms.com), a manager of medical professional liability insurance programs with services that include risk management consultation, education and on-site risk management audits, and other resources offered to health care providers to help improve patient outcomes and reduce professional liability risk. The answers published in this column represent those of only one risk management consulting company. Other risk management consulting companies or insurance carriers might provide different advice, and readers should take this into consideration. The information in this column does not constitute legal advice. For legal advice, contact your personal attorney. Note: The information and recommendations in this article are applicable to physicians and other health care professionals so "clinician" is used to indicate all treatment team members.
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Legal Guidelines for Documentation
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Maintain Confidentiality and Security:
Types of Records I: Unit and Nurses Records
Unit records can be divided into two main types: administrative records and clinical records.
Administrative records in...
Types of Records II: Educational and Administrative Records
Purpose of Health Records I
Here's a breakdown of how health records serve these purposes:
Methods of Documentation II: POMR