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Risk Management Reference Guide - Chapter 2
Medical Records—Documentation and Release

Managing medical records is an ongoing challenge that involves all levels of staff in a practice. Physicians Insurance has developed a number of informative articles and tools to help members address a variety of medical record issues.

Medical Records: Definition, Organization and Charting (PDF 105 KB)
Electronic Medical Records: Litigation Experience and Risk Management Tips 
(PDF 104 KB)
Electronic Medical Records Can Help You Build a Patient SAFE Practice (PDF 35 KB)
Dictation, Documentation and Defensibility (PDF 92 KB)
Telephone Care (PDF 90 KB)
Defending Against the Phantom Phone Call (PDF 93 KB)
Retention of Medical Records (PDF 86 KB)
Tangled Webs and Truth (PDF 109 KB)
The Washington State Uniform Health Care Information Act (UHCIA) (PDF 102 KB)
Responding to a Subpoena for Medical Records or Deposition (PDF 115 KB)
Disclosing Health Care Information in Washington - Q and A (PDF 142 KB)

Back to

Chapter 1: Communication and Rapport

Continue to

Chapter 3: Medical-Legal Issues
Chapter 4: Patient Care Issues
Chapter 5: Practice Management Issues
Chapter 6: Treatment of Minors
Chapter 7: Sample Forms and Letters

View or download the entire Risk Management Reference Guide (PDF 2.5 MB)



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Highlights
Read Washington's and Oregon's Death with Dignity Act.

For EMR tips, see our Physicians Insurance Guide to Adopting Electronic Medical Records.

Check out our Coordinated Quality Improvement Program Plan Template.

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