Question

ownership of the medical record resides with

the provider or

the physician rendering treatment?

Answer 1

Each medical records shall contain sufficient accurate information to identify the patient, support the diagnosis, justify the treatment, document the course and results and promote continuly of care among health care providers. Responsibility for the medical record. The UC director of medical information 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.

Resident physician or allied health professional invlives in the care and documentation with in the patients medical record the attending physician is ultimately responsible for completion of that medical record.