Functions of the Health Record 25 The health record is known by different names in different healthcare settings. crossed out so that it can be seen but not relied onHospital and medical staff disagreements within the health record should be:Dr. Harvey has changed a piece of data in a patient record. Learn vocabulary, terms, and more with flashcards, games, and other study tools. The integrity of EHR documentation is more susceptible than the paper health record to which of the following functions?a. Learn vocabulary, terms, and more with flashcards, games, and other study tools. The records of acute care patients who receive services as hospital inpatients are often called patient records.
Start studying The Legal Health Record Chapter 8. The information that tracks this change and enables a jury to see this change in a medical malpractice action is calledVerbal orders by telephone or in person are discouraged.
Learn vocabulary, terms, and more with flashcards, games, and other study tools. Learn vocabulary, terms, and more with flashcards, games, and other study tools. generated at or for a healthcare organization as its business record Uniform Photographic Copies of Business and Public Records as Evidence Act (UPA)The reproduction of any record retained in the regular course of business and kept by a process that accurately reproduces the original in any medium will be admissible as evidence.Health information manager and information technology personnelPractice setting, federal laws and regulations, and accrediting bodyA requirement per the American Recovery and Reinvestment Act for healthcare data in the EHR and subsequent use of the EHR funtionalities and patient care purposesAn international organization of healthcare professionals dedicated to creating standards for the exchange, management, and integration of electronic informationVerifies the source or origin of the information and the person who created itThe accuracy and completeness of the information.
Is the document the same after having been stored or transmitted as it was at the original time of signing?Ensures that the document cannot later be denied by one of the parties, either the originator or the receiver.Elements that must be included with the method of signature used to authenticate the documentElectronic Signature in Global National Commerce Act (E-Sign)Passed in 2000, gives e-signatures the same legality as handwritten signatures where interstate commerce is involved and provides guidance on how records may be stored and retained electronicallyThe privacy rule establishes that a patient has the right of access to inspect and obtain a copy of his /or her PHIIncludes the health records, billing, and various claims records that are used to make decisions about an individualThe privacy rule affects these situations in which the PHI is handledRequires that a signed consent form be placed in the patient's health record prior to surgeryAHIMA recommends that the operative index be retained forState Law, Federal regulations, accrediting body regulationsHow long does medicare requires records to be maintainedA patient identifying directory that serves as a link to the patient record of information, facilitates the patient identification, and assist in maintaining a longitudinal patient record fro birth to deathBroadly refers to the life cycle of the health record, from the time of creation through the dispositionIn the EHR, the information is longer available for viewing, but is available behind the scenes or through the administrative record view.Federal statute that states that electronic transactions as enforceable as paper transactionsSystem that eliminate hand-written orders and reduce the risk of illegible handwriting and its associated liabilityDetracts from chronology and do not contribute to quality patient care, leaving the organization susceptible to liabilitySpecific, objective, factual with complete inforamtionIn person or over the phone to individuals authorized to receive themMandated by the Joint Commission, hospital must identify, in writing, staff who are authorize to receive and record verbal ordersThe ability to verify the source of a message by identifying its author ans assigning responsibility to that author for entries made within the health record.Only acceptable if allowed by state and federal law as well as payersProvides information about a certain item's content including means of creator, purpose of data, time and date,creator and authorA sub set of e-signature, but instead, encrypts the documentMay be a code, number, or initials, or a method developed by the facilityPresents a legal liability for the healthcare organization and is likely to be non-compliant with federal and state authorization requirementsThe origination or creator of the recorded information attributed to a specific individual or entity actin at a particular timeType of late entry in which information is added to support or clarify a previous entrySurveys organizations to ensure that they comply with legal requirements and their own health record retention policiesIdentifies the federal document that set forth health record content requirementAddressed informed consent for research through its authorization reequirementslaw that requires healthcare institutions that bill medicare or medicaid for services to provide adult patients with information about various types of advance directivesLaw created in 1993, that provides that an individual may give an oral or written instruction to a healthcare provider that remains in force even after the individual losses capacity, and suggests decision-making priority for that individual's surrogatesA committee of at least five members w/varying backgrounds that determines the acceptability of proposed human subjects research in accordance with institutional policies, applicable law and standards of professional practice and conductThe final decision regarding weather consent would be waivedDe-emphasize the use of therapeutic privilege except in extreme cases
Compare and contrast a subpoena, a subpoena ad testificandum, and a subpoena duces tecum. Start studying Legal Health Record. a. be inserted into the space for the date and time written about b. nor be documented more than 24 hours after Start studying Chapter 8 Legal Health Record.