Legal Case Review

Legal Case Review

Introduction

Records management is a management field responsible for the systematic and efficient control of the records' creation and their disposition, including processes for keeping evidence of and information regarding transaction of a patient in the form of records (Health informatics 2006). According to Pickett (2011), medical record is a permanent documentation of the progress and history of medical care of a patient. These records are used as a legal business document drafting the course of medical care of a patient, for patient's care continuity, insurance claims' verification, to provide factual and statistical information for hospital administration, licensing and medical research. Today, comprehending the ethical and legal principles governing health information management has become more significant than ever before (McWay, 2009). This paper aims to successfully navigate the critical legal and ethical requirements in health records management.

Background

I have been appointed as a new administrator for the mental health division of Gotham City medical center, where I am responsible for both the inpatient and outpatient mental health facility and services. A week prior to my appointment, the New York State Office conducted an audit of Mental Health Facility to review the outpatient visits against posted bills to determine if there had been any discrepancies. The primary issues that came to light, during the audit, include the unavailability of written notes regarding the attendance of patients at group meetings and missing of individual documentation for each patient's visit.

Additional findings of the audit include:

The medical records at the mental health clinic were stored in the individual therapist desk drawers which did not have locks and not all of the therapists locked their offices when stepping away for a few minutes.

The psychiatrist in charge often assigned the therapist working with a particular patient to write the psychiatrist's notes in the ...