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Health Information Management |
Scope of Service The medical record is the primary source of client information. It includes data from initial demographic intake to all treatment, observations, diagnostic tests, assessments, etc. during a client's stay. It also includes a summary of the reason for treatment, the significant findings, the procedures performed, treatment, care, recommendations, instructions given to client and/or family, and disposition at discharge. The information included in the medical record is determined by written policies and procedures which govern the content. This includes all medical record forms and documentation. All medical record forms must be screened by the appropriate discipline and the HIMD Director and approved by the Medical Staff Executive Committee. The location of the information in the medical record follows medical record formats for active and discharge records that are approved by the same process as the medical record forms. |