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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....

Assessing and Improving EHR Data Quality: Model for Implementing an EHR Documentation Improvement Process

Author: AHIMA e-HIM Work Group on Assessing and Improving Healthcare Data Quality in the EHR

Source: Journal of AHIMA

Publication Date: March 2007


Improving data quality in an electronic healthcare environment requires a greater focus on standardized documentation procedures. With an EHR, the need to evaluate and improve healthcare data quality through concurrent assessment, data collection monitoring, and ongoing process improvement requ....

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....

Assessing and Improving EHR Data Quality. Appendix A. Case Study: How One Hospital Improved Healthcare Data Quality in Its EHR

Author: Schleis, Kathy

Source: AHIMA web extra

Publication Date: March 02, 2007


Holy Family Memorial Medical Center (HFM), a hospital within a healthcare network, has a hybrid record-part paper, part electronic. In l989, HFM initiated the computerization of the diagnostic areas of the hospital such as the lab and dictated reports. Through the years, system implementation h....

Resolution on the Legal Health Record

Author:

Source: Journal of AHIMA

Publication Date: January 2007

Preamble
Whereas, it is acknowledged that the health care industry is in transition to electronic health records and most health care organizations have health records that are in a hybrid state;
Whereas, for evidentiary and business purposes it is required that healthcar....

Foundational Concepts of the Legal EHR

Author: Quinsey, Carol Ann

Source: Journal of AHIMA

Publication Date: January 2007


The concept of a legal health record (whether paper or electronic) is generally well understood within the HIM profession. However, during the transition from paper to electronic records some organizations are expressing concern about the use of the terms “legal health record” and “legal....

Is Your Electronic Record a Legal Record?

Author:

Source: Journal of AHIMA

Publication Date: January 2007


EHR systems can provide many benefits to patient care. But an EHR system that does not meet the basic requirements of the organization’s business record or legal medical record puts the practitioner or organization at risk.
The risk is real, because the industry has yet to focus sufficientl....

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