CHAPTER 9 LEGAL HEALTH RECORD, MAINTENANCE,
CONTENT, DOCUMENTATION, AND DISPOSITION HIMT
1200 QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) ALREADY GRADED A+
Purposes of the HR Ans✓✓✓Documenting patient treatment and
continuity of care
Proof of services for reimbursement
Proof of quality and effectiveness of care
(for accreditation, licensure, certification)
Support medical research
Support education/training
Support organization's operational activities
Facilitate managerial decision-making to improve quality of patient care
HR: Legal document/evidence in legal actions Ans✓✓✓Adage: If it isn't
documented, it wasn't done
,Legal Health Record (LHR) Ans✓✓✓Business record that would be
disclosed upon valid request
Content of LHR must be identified and managed by inventorying all
source systems contributing to the record: paper/electronic documents
Organizations must determine what becomes part of the LHR, analyzing
inclusions of items such as Ans✓✓✓E-mails
Videos
Metadata
Designated Record Set (DRS) Ans✓✓✓Is used in whole or in part to
make decisions about individuals and includes health records and
records involving billing, insurance enrollment, and coverage
A DRS encompasses more Ans✓✓✓Information than what is usually
considered part of the legal health record
Business Record Ans✓✓✓Is made and kept in the usual course of
business at or near the time of the recorded event
Electronic Health Record (EHR) Ans✓✓✓All documentation is online
,Test results are interfaced
EHR's host features such as Computerized Provider Order Entry (CPOE)
Clinical decision support tools: alerts/reminders
Patient Portals enhance consumer engagement
Capability to mine data conduct analytics
Mobile devices provide means for communication between providers
and patient-physician
Clinical wearable devices- blood sugar monitors/heart monitors feed
info to EHR
Paper vs EHR Ans✓✓✓Large volume and ease of duplication
Persistence: Electronic documents more likely to continue to exist
Metadata: Tracking data about data
Automatic updates
, Obsolescence: With outdated programs or equipment
Searchable and dispersed in multiple locations; more likely with
electronic records
Hybrid Health Records Ans✓✓✓Combination of paper (includes
consents, and advance directives) and electronic components, making
the definition of an LHR even more complex.
Uniform Photographic Copies of Business and Public Records as
Evidence Act (UPA) Ans✓✓✓Both federal and state versions exist
Supports the transition from paper to electronic storage of information
Including any migration of the record from one system/medium to
another
It is imperative that the method used to electronically store information
be reliable and able to accurately reproduce an exact copy of the original
record.
UPA States that the Reproduction Ans✓✓✓Of any record that has been
retained in the regular course of business and kept by a process which
accurately reproduces the original in any medium will be admissible as
evidence
CONTENT, DOCUMENTATION, AND DISPOSITION HIMT
1200 QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) ALREADY GRADED A+
Purposes of the HR Ans✓✓✓Documenting patient treatment and
continuity of care
Proof of services for reimbursement
Proof of quality and effectiveness of care
(for accreditation, licensure, certification)
Support medical research
Support education/training
Support organization's operational activities
Facilitate managerial decision-making to improve quality of patient care
HR: Legal document/evidence in legal actions Ans✓✓✓Adage: If it isn't
documented, it wasn't done
,Legal Health Record (LHR) Ans✓✓✓Business record that would be
disclosed upon valid request
Content of LHR must be identified and managed by inventorying all
source systems contributing to the record: paper/electronic documents
Organizations must determine what becomes part of the LHR, analyzing
inclusions of items such as Ans✓✓✓E-mails
Videos
Metadata
Designated Record Set (DRS) Ans✓✓✓Is used in whole or in part to
make decisions about individuals and includes health records and
records involving billing, insurance enrollment, and coverage
A DRS encompasses more Ans✓✓✓Information than what is usually
considered part of the legal health record
Business Record Ans✓✓✓Is made and kept in the usual course of
business at or near the time of the recorded event
Electronic Health Record (EHR) Ans✓✓✓All documentation is online
,Test results are interfaced
EHR's host features such as Computerized Provider Order Entry (CPOE)
Clinical decision support tools: alerts/reminders
Patient Portals enhance consumer engagement
Capability to mine data conduct analytics
Mobile devices provide means for communication between providers
and patient-physician
Clinical wearable devices- blood sugar monitors/heart monitors feed
info to EHR
Paper vs EHR Ans✓✓✓Large volume and ease of duplication
Persistence: Electronic documents more likely to continue to exist
Metadata: Tracking data about data
Automatic updates
, Obsolescence: With outdated programs or equipment
Searchable and dispersed in multiple locations; more likely with
electronic records
Hybrid Health Records Ans✓✓✓Combination of paper (includes
consents, and advance directives) and electronic components, making
the definition of an LHR even more complex.
Uniform Photographic Copies of Business and Public Records as
Evidence Act (UPA) Ans✓✓✓Both federal and state versions exist
Supports the transition from paper to electronic storage of information
Including any migration of the record from one system/medium to
another
It is imperative that the method used to electronically store information
be reliable and able to accurately reproduce an exact copy of the original
record.
UPA States that the Reproduction Ans✓✓✓Of any record that has been
retained in the regular course of business and kept by a process which
accurately reproduces the original in any medium will be admissible as
evidence
