documentation, amendment, correction, error, medical record, epic, electronic health record, HIM, health information management

The purpose of this policy is to establish parameters for the contents, maintenance, and confidentiality of patient medical records that meet the requirements set forth in federal and state laws and regulations, and to define the portion of an individual’s healthcare information, whether in paper (including microfiche) or electronic format, that comprises the medical record. This policy defines requirements for those components of information that comprise a patient’s complete “legal medical record.”