Legal and Ethical Considerations name Western Governor's University

Legal and Ethical Considerations
A1. Addendum Addendum: Release of Information: Shadow Chart Policy
Shadow charts should only contain copies of the original records. Shadow charts are maintained to assist ancillary departments in treating patients. An original record is created after each treatment for the primary record and a copy can be made for the shadow chart only for convenience in providing care. Original records are not to be kept in shadow charts.
Shadow charts should only contain copies of the original records. This is to ensure that all original documentation is always placed in the main chart. The purpose for this is to have the …show more content…

This directly impacts the staffs' clinical actions. This means that they can not simply treat and release patient. A system has to be in place for counseling young patients or referring them out for counseling and a record of this must be maintained in the medical record chart
C. Health Record Identification
A situation from Montana Code 50-16-603x that could result in a legal claim if not followed correctly is ( 1 ) which states that health-care information may not be released except for statistical purposes, if no identification of individuals can be made from the information released. The organization is responsible for ensuring that the medical record is completely anonymised before releasing it to ensure that the patients identity is not apparent and can not be reasonably ascertained from the medical record alone, or in combination to any other information the user may have access to. If for some reason, potentially identifying information is released such as a home address, a phone number, date of birth or place of employment which could lead to identification of the patient that organization can be found liable for breach of confidentiality.
C1. Confidentiality Policy Statement
In accordance to