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OSHA also requires employers to report on every injury or job-related illness requiring medical treatment (other than first aid) on OSHA Form 300, "Log of Work-Related Injuries and Illnesses" (known as an "OSHA Log" or "Form 300"). An annual summary is also required and must be posted for three months, and records must be kept for at least five ...
The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.
Health information management's standards history is dated back to the introduction of the American Health Information Management Association, founded in 1928 "when the American College of Surgeons established the Association of Record Librarians of North America (ARLNA) to 'elevate the standards of clinical records in hospitals and other medical institutions.'" [3]
The Bureau of Labor Standards of the Department of Labor has worked on some work safety issues since its creation in 1934. [4] Economic boom and associated labor turnover during World War II worsened work safety in nearly all areas of the United States economy, but after 1945 accidents again declined as long-term forces reasserted themselves. [5]
The operative report is dictated right after a surgical procedure and later transcribed into the patient's record. The operative report includes preoperative and postoperative diagnoses, patient condition after surgery, all medications used in association with the procedure, pertinent medical history (Hx) , physical examination (PE), consent ...
During the retention period, specimens are considered to be part of the medical record and must be kept under a CLIA accredited laboratory to ensure compliant handling and storage conditions. [25] [26] If a specimen is sent-out to a non-CLIA biorepository and recalled, the additional testing would not be in compliance. [25]
A retention schedule is a listing of organizational information types, or series of information in a manner which facilitates the understanding and application of the identified and approved retention period, and other information retention aspects.
A kardex (plural kardexes) is a genericised trademark for a medication administration record. [2] The term is common in Ireland and the United Kingdom.In the Philippines, the term is used to refer the old census charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...