Can someone help me with my paper on medical records?The contents of a medical record (basic legal requirements and accreditation requirements of what should be included in a medical record)...

Can someone help me with my paper on medical records?

  • The contents of a medical record (basic legal requirements and accreditation requirements of what should be included in a medical record)
  • Guidelines for how to make an entry, including information on authentication, corrections, and amendments
  • Ownership of medical records
  • Maintaining confidentiality and security of medical records
  • Release of information
    • The section discussing the release of information should include procedures to follow when the release of information is requested by the following individuals:
      • Patient
      • Patient representative
      • Third-party requestors

Asked on by mamma12

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lorrainecaplan's profile pic

Lorraine Caplan | College Teacher | (Level 1) Educator Emeritus

Posted on

I am assuming that you need some help on structuring your paper, rather than that you are looking for the content you need to discuss these issues in medical record-keeping. 

You need to write a first paragraph that introduces the subject of medical record-keeping, perhaps discussing a bit how important it is for patients and medical personnel that these records be kept properly, and listing the topics you must discuss. 

Each of the topics listed in your question should be discussed in a separate paragraph, and each paragraph should have a topic sentence that explains what the topic of the paragraph is.  For example, the paragraph on the release of information might have a topic sentence like this: The release of information to patients or others is governed by federal law.  Each sentence that follows your topic sentence should stay strictly on that topic and not drift into other topics.

Finally, you will need a last paragraph that reminds the reader how important medical record-keeping is and that summarizes the points you covered in the essay.

Much of what you should discuss in this paper is covered by HIPAA, which is the federal statute that controls medical record-keeping, and I have provided a link for you to a summary of the parts of the statute that you need to know about.  

Sources:

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