Preview

Legal Health Record Definition

Good Essays
Open Document
Open Document
558 Words
Grammar
Grammar
Plagiarism
Plagiarism
Writing
Writing
Score
Score
Legal Health Record Definition
University of Illinois at Chicago
A legal health record is “the documentation of healthcare services provided to an individual during any aspect of healthcare delivery in any type of healthcare organization” (AHIMA 2011). Legal health record definitions are diverse within each healthcare organization. The definition of the legal health record is established by the healthcare facility and should meet certain standards (AHIMA, 2011). The legal health record development gets more complicated with the conversion of technology. “Defining the legal health record becomes complex as organizations transition to EHRs with inherent capabilities that do not exist in paper-based records” (Fahrenholz & Russo 2013, p. 31).
It is important to have a well-defined definition of the legal health record. Every healthcare organization is responsible for defining its own legal health record and regulate them with the set requirements by the HIPAA privacy rule (AHIMA, 2011). It is also important to have a defined legal health record to help the hospital get funded, and to uphold and enhance its performance (Cottrell, 2006). The information in these records are crucial to every aspect in healthcare, involving delivery, reimbursement, education, and research (Fahrenholz Russo 2013, p. 45). If the legal health record is not clearly defined, then it could cause problems with …show more content…
Data elements are the basic unit of information that have a unique importance and subcategories that must be standardized and carried throughout the practices (Aspenden, et al., 2004). Specific codes should be recognized in all terminology sets to represent the data elements to ensure data comparability, which will allow all information systems to hold the data as a combined enterprise (Aspeden, et al.,
Continue Reading
View Writing Issues

You May Also Find These Documents Helpful

  • Good Essays

    Cheryl Fahrenholz Chapter 3 Summary
    • 591 Words
    • 3 Pages

    Cheryl Fahrenholz Chapter 3 Summary

    Cheryl Fahrenholz throughout chapter 3 discusses various laws and acts that govern electronic health records and the principal functions that they provide. I picked five of these terms that I believe are the most important. Case management, Credentialing, informed consent, health record and performance improvement. Case-management is one of the most vital parts of any clinical faciality as it is through these individuals that the goals and livelihood of the patient are heard and responded to with corrective measures. The book describes this as an “ongoing review of clinical care conducted” safeguarding the patient against any treatment that is not in their best care (Fahrenholz, page 78 chapter 3).…

    • 591 Words
    • 3 Pages
    Good Essays
    Read More
  • Good Essays

    HS210 Medical office management unit 6
    • 818 Words
    • 4 Pages

    HS210 Medical office management unit 6

    Medical information is the lifeblood of the healthcare delivery system. The medical record contains all of the medical information that describes all aspects of patient care and serves as a communication link among caregivers. Documentation in the medical record also serves to protect the legal interests of the patient, healthcare provider, and healthcare facility. Medical records are important to the financial well being of the facility as they substantiate reimbursement claims. Other uses of medical records include provision of data for medical research, education of health care providers, public health studies, and quality review.…

    • 818 Words
    • 4 Pages
    Good Essays
    Read More
  • Powerful Essays

    Ethical Considerations (HIPAA) For Workers Compensation
    • 81 Words
    • 1 Page

    Ethical Considerations (HIPAA) For Workers Compensation

    HIPAA allows patients’ health information to be disclosed under some circumstances, such as 1) to meet law requirements; 2) for reporting of abuse, neglect, and domestic violence; 3) for monitoring of healthcare operations; 4) to be presented as evidence in legal proceedings; 5) for assistance with police investigation; 6) for medical examinations and funerals; 7) for organ donation; 8) for research; 9) to avoid a significant threat to health or safety; 10) for workers’ compensation payments; 11) to execute government…

    • 81 Words
    • 1 Page
    Powerful Essays
    Read More
  • Good Essays

    Benefits Of HIPAA Privacy And Security Practices
    • 309 Words
    • 2 Pages

    Benefits Of HIPAA Privacy And Security Practices

    The HIPAA Privacy and Security Rules benefit and support the integrity of the healthcare industry, patients, and physicians by supplying the patient with the Notice of Privacy Practices before care is administered. It gives the patient all the pertinent information on how the information in their medical records will be used and shared along with the rights they have to the record. If there are any questions or if the patient feels like the confidentiality of their protected health information has been breached; there is a number contained in the notice for the patient to pose a formal complaint with the Office for Civil Rights (OCR). Also, by allowing patient access to their medical records to confirm the accuracy of the record and revise…

    • 309 Words
    • 2 Pages
    Good Essays
    Read More
  • Powerful Essays

    HIM Principles In Health Information Exchange
    • 3649 Words
    • 15 Pages

    HIM Principles In Health Information Exchange

    AHIMA e-HIM Work Group on Maintaining the Legal EHR. “Update: Maintaining a Legally Sound Health Record—Paper and…

    • 3649 Words
    • 15 Pages
    Powerful Essays
    Read More
  • Satisfactory Essays

    Ethical Dimensions of Meaningful Use Requirements for Electronic Health Records 1
    • 391 Words
    • 3 Pages

    Ethical Dimensions of Meaningful Use Requirements for Electronic Health Records 1

    The Health Insurance Portability Accountability Act (HIPAA) administers the HIPPA Privacy and Security Rules for individual’s protection of their health information. Many doctors and health care providers recognize and accept all requirements under the Security and Privacy Rules. EHR permits health care providers and doctor’s to use data efficiently in their care and to develop the superiority and effectiveness for the betterment of the patient.…

    • 391 Words
    • 3 Pages
    Satisfactory Essays
    Read More
  • Satisfactory Essays

    HCS 430 Week 4 Cindy S Portion
    • 416 Words
    • 6 Pages

    HCS 430 Week 4 Cindy S Portion

    Human Resources Presentation Leslie Gabor, Aisha Little, Anne Parker, and Cindy Wright HCS/430 Legal Issues in Health Care: Regulation and Compliance September 15th, 2014 William Bross Introduction • State and Federal Statutory and Regulatory Enactments. • Current Principles of Patient Consent. • Current State and Future Trends of Physicians’ Rights and Responsibilities. • Current Components and Implications of HIPAA. • Current and Future Trends for Statutory, Regulatory, and Common Law Requirements of Confidentiality.…

    • 416 Words
    • 6 Pages
    Satisfactory Essays
    Read More
  • Good Essays

    Hcs 335 Administrative Ethics Research Paper
    • 585 Words
    • 3 Pages

    Hcs 335 Administrative Ethics Research Paper

    As of today there are issues with the information technology systems, clinical data management systems and the increasing automation of the electronic medical records. All of these present a significant amount of patient privacy and confidentiality issues. When we say confidential, meaning in healthcare we are talking about the protection of a patient’s medical information and keeping their medical information private and safe from any third parties. Administrators are expected to follow the HIPAA Privacy Rule. The HIPAA protects the privacy of patient’s medical information. Patient’s medical records are sensitive personal information that is covered with privacy. There are several ethical…

    • 585 Words
    • 3 Pages
    Good Essays
    Read More
  • Good Essays

    Informatics Proposal: Electronic Medical Records
    • 811 Words
    • 4 Pages

    Informatics Proposal: Electronic Medical Records

    As a group, we are encouraging the physicians to use the technology provided for the benefit of our patients and for this organization. We will identify that electronic medical records (EMRs) and electronic health records (EHRs) is a valuable tool, provide the rationale for why EMRs and EHRs are important, and the legal and ethical aspects. We also will talk about some solutions to put in place to help physicians comply with this technology.…

    • 811 Words
    • 4 Pages
    Good Essays
    Read More
  • Satisfactory Essays

    HIPAA Privacy Analysis
    • 170 Words
    • 1 Page

    HIPAA Privacy Analysis

    Patient care has been vulnerable by HIPAA; healthcare providers cannot easily share patient’s information. Each patient or power of attorney must give implied permission for a healthcare provider to share any personal information. Deprived of not being able to share patient information between providers, it takes longer time to get critical information that can affect patient care. Healthcare organizations faces supplementary legal costs if they violate HIPAA privacy provisions. These costs make many organizations careful of sharing a patient information, even if the patient has given permission for information sharing, so that’s why everything has to be documented, initial, and signed.…

    • 170 Words
    • 1 Page
    Satisfactory Essays
    Read More
  • Satisfactory Essays

    Hcs 483 Wk1Dq1 2
    • 457 Words
    • 2 Pages

    Hcs 483 Wk1Dq1 2

    Prior to the enactment of the Health Insurance Portability and Accountability Act (HIPPA) health information was able to be shared without the knowledge or permission of the patient. This information was available to just about anyone including insurance agencies, places of employment and even loan lenders. People would potentially use individuals’ health information to deny them work or a loan for their home and even impacting higher insurance rates or denial of coverage. According to U.S. Department of Health and Human Services (n.d.), “The Privacy Rule establishes a Federal floor of safeguards to protect the confidentiality of medical information. State laws which provide stronger privacy protections will continue to apply over and above the new Federal privacy standards.” (para. 1). Also, as medical records continue to move entirely to the new standard of electronic records it is important to have one standard across the country to protect everyone’s information. Electronic health records (EHR) make it easier than ever to accidentally share medical information, to include having it stolen. Medical providers are just as likely to face consequence if their facility is broken in to and the hard drive with patients information is stolen as they would be if they gave the information away themselves. In general HIPPA protects patients’ information as well as their right to be treated equally.…

    • 457 Words
    • 2 Pages
    Satisfactory Essays
    Read More
  • Satisfactory Essays

    Hipaa
    • 384 Words
    • 2 Pages

    Hipaa

    | HIPAA Rules (1) Privacy Rules: involves federal protection of a person’s health information and guarantees a patient’s rights and to prevent healthcare fraud and abuse. This is important when it comes to identity theft with fraud health insurance, protects a person’s diagnosis and treatment, and all personal information. This also sorts out what information can be given to staff and third parties. (2) Security Rules: Mandated sets of rules that helps the loyalty of administration, physical, and technical information. It allows insured entities to look into policies to improve patient care. Security rules are important in the Electronic Health Record. Impacts staff in what they can access and what members and organizations that need to maintain correct information. (3) Standardized transaction code sets rules:…

    • 384 Words
    • 2 Pages
    Satisfactory Essays
    Read More
  • Best Essays

    Privacy Concerns with Electronic Medical Records
    • 1982 Words
    • 57 Pages

    Privacy Concerns with Electronic Medical Records

    It is important for the purpose of clarity to distinguish the difference between electronic medical records (EMR) and electronic health records (EHR). Electronic medical records are an electronic composition of an individual’s medical history including such components as procedures, past diseases, diagnosis, medications, doctor’s names, and allergies. An electronic health record is an electronic means of documenting a patient’s procedures, diagnosis, billing information, etc. at each care facility (Badzek & Gross, 1999). A movement that was first initiated under the Bush administration, accepted by the Clinton administration, and now embraced by President Obama is the creation of the individual electronic medical record. In 2009 President Obama included $36 billion in the stimulus package to create electronic record systems, with the idea that technology will cut costs,…

    • 1982 Words
    • 57 Pages
    Best Essays
    Read More
  • Powerful Essays

    HCS 335: Patient Privacy Issues
    • 1410 Words
    • 6 Pages

    HCS 335: Patient Privacy Issues

    Medical records consist of private health information that should remain private unless direct written consent is given by the patient. Information technological advances are coming at a rapid pace and the laws designated to protecting the patient 's right to privacy are being surpassed. It is then the responsibility of the healthcare provider to ensure that he or she is doing whatever necessary to protect the patient. It is the responsibility of the healthcare manager to ensure that all staff members are properly trained to handle the PHI that they have access to. All healthcare organizations should take steps to ensure that their organization is doing all that they can to be compliant with guidelines that are stated within federal and state laws, including using safeguards and implementing a formal information management plan. After all, the patient should be comfortable and able to trust those providing healthcare services to him or her enough to provide all pertinent information to be properly diagnosed and treated.…

    • 1410 Words
    • 6 Pages
    Powerful Essays
    Read More
  • Powerful Essays

    Legal System
    • 5778 Words
    • 24 Pages

    Legal System

    References: McWay, JD, RHIA, D. C. (2010). Legal and Ethical Aspects of Health Information Management (Third ed.). Clifton Park, NY: Delmar, Cengage Learning.…

    • 5778 Words
    • 24 Pages
    Powerful Essays
    Read More

Related Topics