What is a medical record?
The medical record is a legal document that contains sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers.
Who owns the medical record?
Healthcare facilities initiate and maintain a medical record for every individual assessed or treated. The facility collecting the information owns the record.
Is my health information kept confidential?
Releasing information is a routine and necessary activity in a health care facility to facilitate communication among caregivers and to allow the enterprise to carry on its daily operations. However, the patient’s right to privacy and confidentiality, which is protected by law, must be observed. Access to information is based on the “need to know” principle. No healthcare information (unless for a reason documented below) is released without a signed authorization form by the patient.
Slocum-Dickson Medical Group ensures that all healthcare information, whether in paper or electronic form, is kept strictly confidential.
What is the purpose of the medical record?
The purpose of the medical record is:
- To facilitate patient care
- Serve as a financial and legal record
- Aid in clinical research
- Support decision analysis
- Guide professional and organizational performance improvement
How do I contact Medical Records?
To contact our Medical Records Department, call us at 315-798-1498.