MEDICAL RECORDS MANAGEMENT CHECKLIST: HIPAA & ACCURACY

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--- RECORD CREATION & ACQUISITION ---
[ ] Date of Service
[ ] Time of Service
[ ] Record Type (e.g., Progress Note, Consultation) (Progress Note, Consultation, Admission Note, Discharge Summary)
[ ] Chief Complaint/Reason for Visit
[ ] Source of Information (Patient, Family Member, Other Healthcare Provider)
[ ] Vital Signs - Temperature (Fahrenheit)
[ ] Supporting Documentation (Optional)

--- PATIENT IDENTIFICATION & DEMOGRAPHICS ---
[ ] Patient Full Name
[ ] Date of Birth (YYYY-MM-DD)
[ ] Medical Record Number (MRN)
[ ] Patient ID Number
[ ] Gender (Male, Female, Other, Unknown)
[ ] Preferred Language
[ ] Address Line 1
[ ] Address Line 2

--- HIPAA COMPLIANCE - ACCESS CONTROLS ---
[ ] Access Level Verification Method (Role-Based Access Control (RBAC), Attribute-Based Access Control (ABAC), Other (Specify))
[ ] Multi-Factor Authentication (MFA) Status (Implemented for all users, Implemented for specific roles, Not implemented)
[ ] Number of Authorized Users
[ ] Audit Log Monitoring (Real-time monitoring, Scheduled reviews, No monitoring)
[ ] Last Access Control Review Date
[ ] Notes on Access Control Procedures

--- DOCUMENTATION COMPLETENESS & ACCURACY ---
[ ] Chief Complaint Documentation
[ ] History of Present Illness (HPI)
[ ] Physical Exam Findings
[ ] Assessment/Diagnosis
[ ] Plan of Treatment
[ ] Vital Signs - Temperature (F)
[ ] Vital Signs - Blood Pressure (Systolic)
[ ] Vital Signs - Blood Pressure (Diastolic)
[ ] Allergies Documented? (Yes, No, Unknown)

--- RECORD STORAGE & SECURITY ---
[ ] Physical Record Storage Location Verified? (Yes, No)
[ ] Electronic Records Encryption Status? (Enabled, Disabled, Not Applicable)
[ ] Access Log Review Frequency (Days)
[ ] Firewall Protection Active? (Yes, No, Not Applicable)
[ ] Last Security Audit Date
[ ] Notes on Physical Security Measures

--- RECORD RETENTION & DISPOSAL ---
[ ] Record Retention Start Date
[ ] Retention Period (Years)
[ ] Record Format (e.g., Paper, Electronic) (Paper, Electronic)
[ ] Specific Retention Rationale (if applicable)
[ ] Disposal Method (Shredding (Paper), Secure Deletion (Electronic), Certified Destruction Service)
[ ] Scheduled Disposal Date
[ ] Authorized Personnel Signature (Disposal)

--- RELEASE OF INFORMATION ---
[ ] Release Type (Patient Request, Legal/Court Order, Insurance Authorization, Other (Specify))
[ ] Purpose of Release (if applicable)
[ ] Requester Name
[ ] Requester Contact Information (Phone/Email)
[ ] Record Format (Paper, Electronic (Secure Email), CD/DVD, Other (Specify))
[ ] Release Date
[ ] Release Time
[ ] Authorized Release Personnel Signature

--- AUDIT TRAIL REVIEW ---
[ ] Audit Review Date
[ ] Number of Records Reviewed
[ ] Review Type (Routine, Incident-Related, Periodic Security Audit)
[ ] Summary of Findings
[ ] Compliance Status (Compliant, Minor Deviation, Major Deviation)
[ ] Corrective Actions Required (if any)
[ ] Corrective Action Completion Date (if applicable)
[ ] Reviewer Signature

--- DISASTER RECOVERY & BUSINESS CONTINUITY ---
[ ] Last DR/BC Plan Review Date
[ ] Backup Frequency (Daily/Weekly/Monthly)
[ ] Backup Storage Location (Onsite/Offsite/Cloud) (Onsite, Offsite, Cloud)
[ ] Summary of DR/BC Procedures
[ ] Last Successful Data Restore Test Date
[ ] Estimated Time to Restore Core Systems
[ ] Critical Systems Identified for Recovery (Electronic Health Record (EHR), Billing System, Patient Portal, Lab Information System (LIS), Pharmacy System)

--- TRAINING & AWARENESS ---
[ ] Last Training Date
[ ] Training Modules Completed (HIPAA Privacy Rule, HIPAA Security Rule, Medical Records Management, Data Breach Response, Other (Specify))
[ ] Specify 'Other' Training (if applicable)
[ ] Training Format (Online, In-Person, Hybrid)
[ ] Score on Post-Training Assessment (if applicable)
[ ] Upload Proof of Training Completion (e.g., certificate)
[ ] Trainer Name

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