Medical Record Retention and Maintenance for Private Practices

The medical record provides documentation of pertinent clinical and laboratory findings, diagnosis, therapeutic actions taken, patient progress and response to therapy, and instructions to the patient regarding physical activity, medication, diet, and follow-up care. Meticulous record-keeping in the...

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Bibliographic Details
Published inJournal of the American Dietetic Association Vol. 109; no. 11; pp. 1838 - 1841
Main Authors Stein, Karen, MFA, Hager, Mary H., PhD, RD, FADA
Format Journal Article
LanguageEnglish
Published United States Elsevier Inc 01.11.2009
Elsevier Limited
Subjects
Clinical medicine
Dietetics
Dietitians
Electronic Health Records
Forms and Records Control - legislation & jurisprudence
Forms and Records Control - organization & administration
Gastroenterology and Hepatology
Health care policy
Humans
Information Management
Information Storage and Retrieval
Internal Medicine
Medical Records
Medical Records Systems, Computerized - organization & administration
Private Practice - legislation & jurisprudence
Private Practice - organization & administration
Records retention
Time Factors
United States
United States
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Summary:The medical record provides documentation of pertinent clinical and laboratory findings, diagnosis, therapeutic actions taken, patient progress and response to therapy, and instructions to the patient regarding physical activity, medication, diet, and follow-up care. Meticulous record-keeping in the health care practice is essential because it enhances the health care practitioner's ability to assess and monitor patient care and ensures accurate transmission of information from one practitioner to another across the continuum of care. Here, Stein and Hager discuss how to retain and maintain medical record for private practices. They point out that registered dietitians should expect the information to evolve further as EMRs eventually become the standard, which the federal government has expressed as its goal. To be on the safe side, practitioners should consider following the suggestions for longer retention periods and robust record-keeping as a matter of optimizing patient care and safety and of personal protection in the event of litigation.
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ISSN:0002-8223
2212-2672
1878-3570
2212-2680
DOI:10.1016/j.jada.2009.09.014