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Medical Records of Every Patient

The hospital has to have medical records of every patient, administrators of which must be held responsible for them. Medical records should have participation standards in order not to get lost in all the documents. Hospital standards have several sub standards, which would also be discussed in the paper.

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Standard Explanation Substandard
The first standard has to concern organization and staffing, which means that the service’s organization must make everything according to the complexity of the services. The people who work with the records have to be adequate, and they have to complete everything swiftly and carefully (Rothstein & Tovino, 2019). Any leakage of the papers can be considered a personal responsibility of the administration because the filing and retrieval of the records should be prompt.
The second standard concerns the repetition of records, which means that the hospital needs to ensure that the medical records for both inpatient and outpatient care exist. Medical records must be accurate, properly filed, and have easy access for the medical staff, such as nurses (Rothstein & Tovino, 2019) The rules substandard are that the medical records have to be retained in their original form or recreated to the structure, which is less than five years old (Rothstein & Tovino, 2019). The second substandard is about coding and indexing medical records, which have to allow the timely retrieval of the needed information. Moreover, the patient’s confidentiality has to be ensured, meaning that only people with authority have access to the required files.
The third standard is about the medical records’ content, which means that they have to contain only essential information and the knowledge of the past serious illnesses. According to the standards, the substandard for that rule is the legitimized documents used, timed, dated, and authenticated (Rothstein & Tovino, 2019). The orders, even the verbal ones, have to be dated and timed as well. Hospitals can use the previously printed orders, and they do not have to create everything by hand.


Rothstein, M. & Tovino, S. (2019). Privacy risks of Interoperable Electronic Health Records: Segmentation of sensitive information will help. The Journal of Law, Medicine & Ethics, 47(4). Web.

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