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Yellow Brick Road Assisted Living Case Study

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Medical Records Policy
Yellow Brick Road Assisted Living must maintain the medical records on all patients in line with professionally accepted practices and standards. This is regardless of their format and form. No medical entry may be deleted from the record except in cases deemed necessary by the destruction policy provided by the state and federal laws and the Yellow Brick Road Assisted Living policies and procedures (Woodcock & Wam, 2006). Patient entries should be made as soon as possible following the encounter of a health practitioner with a patient. Records must contain and not limited to the following attributes:
a. Patient identification details such as name, physical address, date of birth, contact numbers, and emergency contacts. …show more content…
Data integrity-protection of information against unauthorized and accidental manipulation.
c. Non-repudiation-preventing persons signing the information entered from denying authenticity of their signatures.
Responsibility of the Medical Records
a. All medical records of patients received by Yellow Brick Road Assisted Living are the property of Yellow Brick Road Assisted Living. The information must be made available to the patient upon request and subsequent authorization.
b. Yellow Brick Road Assisted Living must ensure the records are not removed from the designated storage areas unless under court orders and other requirements by the law.
c. Yellow Brick Road Assisted Living shall maintain the safety and security of the medical records to safeguard against loss and destruction.
d. Yellow Brick Road Assisted Living is responsible for documenting patient medical records within the designated time periods.
Destruction of Medical Records
Yellow Brick Road Assisted Living shall retain all medical records in accordance to the state and federal laws and also the Yellow Brick Road Assisted Living policies and procedures (College of Physicians & Surgeons of Nova Scotia, 2008). Legal requirements also define the time frames for the retention of electronic documentation of patient

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