Laws regarding promptly updating medical records

23-Aug-2017 09:17

Except in an emergency, before a maternity patient may be admitted to a hospital, the patient's attending physician shall submit a legible copy of the prenatal history to the hospital's obstetrical staff.The prenatal history shall note complications, Rh determination and other matters essential to adequate care.There shall be appropriate, ongoing training programs available to all nursing service personnel to augment their knowledge of pertinent new developments in patient care and to maintain current competence.Hospital policies affecting the nursing service shall be developed and reviewed with the participation of the director of nursing or designee.Sometimes health care providers outsource this “business” to third-party companies, and sometimes the hospitals and health systems play the con game themselves.Federal law is quite clear: a patient has the “right to obtain from [their health care providers] a copy of [their medical records] in an electronic format,” 42 USC § 17935(e)(1), and that health care provider is allowed to bill “only the cost of …

laws regarding promptly updating medical records-59

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Individual surgical technologists and licensed practical nurses may function as assistants under the direct supervision of a qualified registered nurse.

The hospital shall have policies regarding use of these personnel in the facility.

Written consent of the patient or the patient's legally authorized representative shall be presented as authority for release of medical information to persons not otherwise authorized to receive this information.

When temporary nursing personnel from outside registries or agencies are used by the hospital, the nursing service shall have a means for evaluating the credentials and competence of these personnel.

laws regarding promptly updating medical records-7

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Temporary nursing personnel shall function under the direction and supervision of a qualified registered nurse from the hospital nursing staff.Only members of the medical staff or other professional personnel authorized by the medical staff shall record and authenticate entries in the medical record.

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