Medical Records (Revised 12-12-19)
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Modified on: Fri, 13 Dec, 2019 at 3:22 PM
MR 1.0 - Medical Records Maintenance, Storage and Handling |
Standard: The entity must have policies and procedures in place for proper maintenance, storage and handling of medical records. |
Elements of Compliance:MR 1.1 The entity must maintain medical imaging records for each patient for at least 5 years or as required by the state. Assessment: Review a sample of records for compliance with date maintenance.MR 1.2 The entity must maintain records electronically or physically in a secure, protected area.MR 1.3 The entity must have a process for filing and retrieving the medical record.MR 1.4 Upon written request from the patient the entity must have a process for transferring images or reports within 2 weeks.
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MR 2.0 - Confidentiality of Medical Records |
Standard: The entity must ensure confidentiality of medical records. |
Elements of Compliance:MR 2.1 The entity must have policies and procedures for obtaining information from a patient medical record, in whole or part.MR 2.2 The entity must have a process for proper authorization and release of information from the medical record.MR 2.3 Original medical records should be released only in accordance with Federal and State laws, court orders or subpoenas.MR 2.4 At the time of the examination, the entity must inform patients about how to obtain their images and medical records. Images or reports must be provided in a manner that is useful to the recipient, e.g. media capability of recipient determined.
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MR 3.0 - Medical Record Completeness |
Standard: The entity creates medical records that are uniform, consistent and complete for each patient. |
Elements of Compliance:MR 3.1. The medical record should be complete and contain copies of reports, films, scans or other image records.MR 3.2 The content and format of patient records are consistent and must include at minimum:NameIdentification numberDate of birthGenderResponsible party
MR 3.3 The patient record contains up-to-date information on allergies or material/drug reactions in a prominent and uniform location.MR 3.4 Radiology reports contained in the medical record should be signed by the interpreting physician.
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Revision History for this Article |
Date | Section | Description of Revision(s) |
12-12-19 | All | Article created; FAQs incorporated; No criteria changes |
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