Based on the committees clinical direction the first step in defining the legal health record and designated record set is to determine what legal entities enforce relevant regulations guidelines standards or laws on health records. Medical records documentation of patient care in the legal health record from a risk management perspective the legal health record is generally the information used by the patient care team to make decisions about the treatment of a patient policies must dictate what is and is not an acceptable amendment the following describes . The health care provider or health plan must respond to your request if it created the information it must amend inaccurate or incomplete information if the provider or plan does not agree to your request you have the right to submit a statement of disagreement that the provider or plan must add to your record. Intro health informatics q4 ch 10 12 study play the legal health record for disclosure consists of laws decisions and guidance for the processes and evidence used in civil trials federal rules of civil procedure it is important to have all stakeholders involved in the development of a legal health record policy of the following . The legal health record copy and paste guidelines ahima 2009 him webinar series 3 notes comments questions toolkit overview content 1 him professional responsibilities
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