Electronic Medical Records Policy And Procedure Template

The purpose of this policy is to identify the health record of organization name s for business and legal purposes during and after the transition to electronic health records and to ensure that the integrity of health records is maintained during and after this period so that it can support business and legal needs.

Electronic medical records policy and procedure template. The records management policy and outreach program under the office of the chief records officer for the u s. Access to electronic health records at university hospital policy revised august 11 2011 page 3 of 4 2. 1 2 and 3 above will be granted automatic limited access to the appropriate ehr programs without requirement for application to medical informatics committee. This policy should be tailored by the party responsible for the custodianship of an agency s or department s electronic records to the agency s specific electronic records management practices wherever. Electronic health record ehr use of templates and copying functionality page 2 of 5.

Section 4 13 implement ehr and hie policies and procedures checklist. The health record provides the basis for planning patient care and continuity of that care and its accuracy is critical to patient safety and the best outcomes. Policies and procedures for electronic health record use. Disclaimer the material in these guides and tools was developed from the experiences of regional extension center staff in the performance of technical support and ehr implementation assistance to primary care. Care items and services provided.

Use sample checklist 2. Individuals listed in category a. Place a check next to each ehr feature or action if it is included in the existing policies and procedures. Policies and procedures when creating or updating policies and procedures to ensure ehr related program integrity vulnerabilities are addressed. The medical record contents can be maintained in either paper hardcopy or electronic formats including digital images and can include patient identifiable source information such as photographs films digital images and fetal monitor strips and or a written or dictated summary or interpretation of findings.

Electronic records generated by imaging systems. Government is responsible for developing federal records management policies and guidance related to records creation management and disposition with an emphasis on electronic records. To provide guidance on instances in which an amendment and or late entry is necessary to support the integrity of the health record. As you implement an electronic health record ehr health information exchange hie service or other health information technology hit many existing policies and procedures will probably need review and modification. The purpose of this policy is to establish the standards and criteria for the appropriate use of the ehr in order to meet federal and state rules and regulations regarding appropriate.