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Charting the Legal Health Record

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: May 2007


Tracking what should or shouldn’t be included in a healthcare organization’s legal health record can be a dizzying process without ample organization. The increasing mix of digital information with traditional paper records makes good organization all the more essential.

HIM pr....

Subpoena by Any Other Name Might Not be Legal

Author: Whitney, Jo Ellen

Source: Journal of AHIMA

Publication Date: May 2007


Generally when an opposing party is seeking medical records from a care provider, the first request is accompanied by a subpoena, which can be difficult for an HIM department to assess in terms of what-if any-records can be produced.

A subpoena accompanied by a HIPAA-compliant consen....

Legal EHR: New Practices, New Skills

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: May 2007


Defining the legal EHR is a key strategy that AHIMA has been working on for several years. The FORE Library: HIM Body of Knowledge is growing on this important topic thanks to the work of HIM, legal, and IT experts serving on AHIMA’s e-HIM® work groups. In addition, an HIM-led Health Level S....

Policies and Procedures for a Legal EHR

Author: Quinsey, Carol Ann

Source: Journal of AHIMA

Publication Date: April 2007


As organizations move from paper to electronic health records (EHRs), one of the most critical steps is ensuring that there are policies that support the EHR as the legal health record.

Most managers know the importance of having up-to-date policies and procedures. Good pol....

Linking Anti-fraud and Legal EHR Functions

Author: Dougherty, Michelle

Source: Journal of AHIMA

Publication Date: March 2007


The following statement could easily come from any material written on the legal electronic health record: “EHRs and information available through the NHIN [nationwide health information network] must fully comply with applicable federal and state law and meet the requirements of reliability an....

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