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Medical Records Protocol: Abstract: This document covers the standard protocol to ... Please have a look at the product here: Medical Records Protocol ...

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Q: Process to prepare the protocol of Medical Records?
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What process would you follow in order to provide a patients record to the court?

Prepare and properly serve a subpoena duces tecum on the custodian of the records to appear in court with the records and be ready to testify that they are either the actual records of the patient or true copies of same. Federal laws prohibit disclosure of most patient medical records unless they are relevant to the issues at trial. Thus, a custodian of the records will probably not produce the records unless subpoenaed to do so or if the patient or the patient's legal personal representative authorizes the release.


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Medical Records and Health Information Technician?

Electronic medical records is a vital component of today’s patient records. Currently, all medical facilities have not yet converted all files to the computer, but the majority of facilities are working on it. The emphasis of electronic medical records creates increased opportunities for the medical records and health information technician. A patient’s medical file can mean life or death for them. Thus, it is critical for the information to be completely accurate. There are many jobs that fall within the umbrella of medical records and health information technician. For example, the medical billing and coding specialist falls under this area. A medical biller and coder is a professional that codes patient records and creates billing statements for reimbursement. A medical transcriptionist is another job that falls under a medical records and health information technician. This professional must take recorded information and convert it to a digital file. The digital file becomes the patient’s medical record. This information determines the care and services the person will receive. The medical records of a patient are sensitive information. It is critical that these files be absolutely accurate. Thus, the successful medical records and health information technician will be detail-oriented. Additionally, training from an accredited college or university is required to become a medical biller and coder. Medical transcription also requires proper training from a program that is accredited. Most students that take courses in medical billing and coding can complete them within 1-2 years. An associate degree can be obtained during the two year program. The one year program grants a certificate. Those medical records and health information technicians that want to advance quickly should become certified. Transcription and medical billing and coding have certification exams that can result in a certified status. The increase of senior patients will result in more visits to medical facilities. This influx of patients will create more demand for all medical records positions. Those that enjoy administrative work usually are a good fit for this profession. The U.S. Labor Department predicts that jobs will increase in the next decade. Those that prepare now will be in a good position to reap the rewards of future job opportunities.


Involves the review and evaluation of the records that are used to prepare the organization's financial statements?

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