21.4.09
RETAINING AND TRANSFERRING
Generally speaking, physicians must always keep theoriginal medical record themselves. Only copies of therecord should be transferred to others.Retaining Medical RecordsRegulation requires that physicians keep medicalrecords for a certain period of time. For adultpatients, the rule is that records must be retained...
20.4.09
Three Different Types of External Review
Medical records must meet expectations for three differenttypes of external review: quality assurance, legal,and auditing. A good record will provide enoughinformation to satisfy inquiries made by any of thesebodies. The following specific examples of informationto be included in records of particular types ofencounters...
20.4.09
Patient Non-Compliance or Failure to Attend Appointment
Physicians should document all instances of a patientrefusing an examination. Most physicians have had anexperience where a patient has refused to have anexamination or a specific portion of an examination,or asked to defer the examination to a later date. It isessential that physicians document all advice, tests...
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