What does a certified medical record mean?

Since medical records are not public documents, the records are required to be “certified”. What is a certified medical record? This means that a notary (in most states) must witness that the copy is the same as the original. The subpoena must be “served” or given to the provider whose records are requested.

What is the significance of the medical record for the healthcare professional?

For health professionals, good medical records are vital for defending a complaint or clinical negligence claim; they provide a window on the clinical judgment being exercised at the time. The presence of a complete, up-to-date and accurate medical record can make all the difference to the outcome.

What is the importance of a patient’s medical record?

A good medical record serves the interest of the medical practitioner as well as his patients. It is very important for the treating doctor to properly document the management of the patient under his care. Medical record keeping has evolved into a science.

What is a custodian affidavit?

When the company turns over records in response to a subpoena, an employee of the company who is familiar with the records verifies that the records are authentic by signing an affidavit. Many subpoenas include a form affidavit for the document custodian to complete and return to the party that requested the records.

What are the three main reasons medical records are kept in a healthcare facility?

Proper documentation, both in patients’ medical records and in claims, is important for three main reasons: to protect the programs, to protect your patients, and to protect you the provider. Good documentation is important to protect our programs.

Why record keeping is important in nursing?

It also ensures that the professional and legal standing of nurses are not undermined by absent or incomplete records, if they are called to account at a hearing. Good record-keeping promotes better communication as well as continuity, consistency, and efficiency, and reinforces professionalism within nursing.

What are the four major purposes of the medical record?

They provide documentation of a patient’s continuing health care from birth to death. They provide a foundation for managing a patient’s health care. They serve as legal documentation in lawsuits. They provide clinical data for education, research, statistical tracking, and assessing the quality of health care.

What does it mean to be a custodian of records?

Records custodian means the person responsible for the maintenance, care or keeping of a public body’s public records, regardless of whether the records are in that person’s actual physical custody and control.

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