A.  All Medical Records of UC__ patients, regardless of whether they are created at, or received by, UC__, and patient lists and billing information, are the property of UC__ and The Regents of the University of California.  The information contained within the Medical Record must be accessible to the patient and thus made available to the patient and/or his or her legal representative upon appropriate  request and authorization by the patient or his or her legal representative.

http://medical-record.blogspot.com/
    

B.  Responsibility for the Medical Record. The UC__ Director of Medical Information (Health Information Services) is designated as the person responsible for assuring that there is a complete and accurate medical record for every patient.  The medical staff and other health care professionals are responsible for  the documentation in the medical record within required and appropriate time frames to support patient care. 

C.  Original records may not be removed  from UC__ facilities and/or offices except  by court order, subpoena, or as otherwise required by law.    If an employed physician or provider separates from or is terminated by the University for any reason, he or she may not remove any original Medical Records, patient lists, and/or billing information from UC__ facilities and/or offices.  For continuity of care purposes, and in accordance with applicable laws and regulations, patients may request a copy of their records be forwarded to another provider upon written request to UC__.

D.  Medical records shall be maintained in  a safe and secure area.  Safeguards to prevent loss, destruction and tampering will be maintained as appropriate.  Records will be released from Health Information Management Services only in accordance with the provisions of this policy and other UC__ Privacy Policies and Procedures. 

E.  Special care must be exercised with Medical Records protected by the State and federal laws covering mental health records, alcohol and substance abuse records, reporting forms for suspected elder/dependent adult abuse, child abuse reporting, and HIV-antibody testing and AIDS research. (Refer to Policy No. _____. “Authorization for Use/Disclosure of PHI”.)

F.  Chronology is essential and close attention shall be given to assure that documents are filed properly, and that information is entered in the correct encounter record for the correct patient, including appropriate scanning  and indexing of imaged documents.
http://medical-record.blogspot.com/