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Fundamentals of the Legal Health Record and …

    https://library.ahima.org/doc?oid=104008
    An organization's legal health record definition must explicitly identify the sources, medium, and location of the individually identifiable data that it includes (i.e., the data collected and directly used in documenting healthcare or health status).

Complying With Medical Record Documentation …

    https://www.hhs.gov/guidance/document/complying-medical-record-documentation-requirements-fact-sheet
    Complying With Medical Record Documentation Requirements Fact Sheet Learn about proper medical record documentation requirments; how to provide …

Defining the Medical Record: Relationships of the Legal …

    https://perspectives.ahima.org/page/defining-the-medical-record-relationships-of-the-legal-medical-record-the-designated-record-set-and-the-electronic-health-record
    For many people, all information contained in the electronic health record (EHR) is synonymous with “medical record” or even “legal medical record.” This is an erroneous …

Clinical documentation | How to document …

    https://onthewards.org/how-to-document-well/
    A medical record is a legal document. So, understand that what you write is memorialised permanently. In the case of any …

Guidelines for Medical Record Documentation

    https://www.ncqa.org/wp-content/uploads/2018/07/20180110_Guidelines_Medical_Record_Documentation.pdf
    Personal biographical data include the address, employer, home and work telephone numbers and marital status. All entries in the medical record contain the author’s …

Legal Process and Electronic Health Records - AHIMA

    https://library.ahima.org/doc?oid=59559
    Legal Process and Electronic Health Records Legal Process and Electronic Health Records The custodian of an electronic health record (EHR) has the same concerns as …

10 Components Of a Medical Record? The Best Guide …

    https://digitalhealth.folio3.com/blog/10-components-of-a-medical-record/
    Explain the Components Of Medical Records What Are The 10 Components Of A Medical Record? 1. Identification Information 2. Medical History 3. Medication …

The medical record: A legal document — Can it be …

    https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2009/the-medical-record-a-legal-document-can-it-be-corrected
    Navigating legal or regulatory processes The medical record: A legal document — Can it be corrected? 8 minutes Published: October 2009 The information in this article was …

The Medical Record | Manual - Risk Management

    https://www.ihs.gov/riskmanagement/manual/manualsection05/
    The Medical Record Risk Management Manual Introduction to the Third Edition Healthcare Risk Management Underlying Influences That Often Lead to Claims of Malpractice The …

3 Legal Documents Caregivers Need to …

    https://www.agingcare.com/Articles/legal-documents-to-make-healthcare-decisions-for-your-parent-146623.htm
    The Health Information Portability and Accountability Act (HIPAA) provides legal standards for keeping a person’s health information and records private. This means it is illegal for medical professionals to …



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