CH.9 LEGAL HEALTH RECORD:
MAINTENANCE, CONTENT,
DOCUMENTATION, AND DISPOSITION.
EXAM QUESTIONS AND ANSWERS 100%
PASS
Business Record - ANS -Made & kept in usual course of business at or near the time of a
recorded event
Legal Health Record - ANS -Used for legal purposes and is the record released upon a valid
request
-Organization's official health record of patient
-Content varies from organization to organization
-No one-size fits all definition b/c laws and regulations governing the maintenance, content, and
documentation requirements of health record vary by practice, state, & fed law and regulations
Designated Record Set (DRS) - ANS HIPAA covered entity that A. are medical or billing
records; B. enrollment, payment, claims adjudication, and case or medical management record
systems; C. used in whole or part by or for covered entity to make decisions about individuals
-Encompasses more info than a LHR
Uniform Photographic Copies of Business & Public Records as Evidence Act (UPA) - ANS -
Supports transition from paper to electronic storage info
@COPYRIGHT ALL RIGHTS RESERVED PAGE 1 OF 15
, -Federal and State versions, states reproduction of any record retained in the regular course of
business & kept by process accurately & reproduce original in any medium.
Conditions of Participation (CoP) - ANS -The standards that govern providers receiving
Medicare and Medicaid reimbursements
-Require health records contain info to justify admission & continued hospitalization
The Joint Commission - ANS -Accredits healthcare organizations
-Requires health records be maintained and that content and documentation standards be
followed
Gaps & Omissions - ANS -Gaps are spaces left between entries in the paper health record
-spaces allow subsequent entries to be made in a space previous to an already existing entry--
prevent info from being added out of sequence
-Long periods of time without documentation can also hamper patient care when entered late
or not at all
Physician Order - ANS -one of most important pieces of documentation in health record
-Accuracy of medication orders is extremely important
-Order for admin of medicine such as narcotics & sedatives have time limits or stop orders-
automatically discontinue meds unless physician gives specific order to cont.
-written and verbal orders
-physician assistant and nurse practitioners have ability to give orders and prescribe meds
Verbal Orders - ANS -2 types
-Communicated in person or over the phone to individuals authorized to receive them
-high risk associated w/verbal orders = discouraged to use
-If provider is present he/she should document order instead of dictating to personnel
-Joint Commission established rule to "read back" orders
-All orders must be authenticated by provider who gave order
@COPYRIGHT ALL RIGHTS RESERVED PAGE 2 OF 15
MAINTENANCE, CONTENT,
DOCUMENTATION, AND DISPOSITION.
EXAM QUESTIONS AND ANSWERS 100%
PASS
Business Record - ANS -Made & kept in usual course of business at or near the time of a
recorded event
Legal Health Record - ANS -Used for legal purposes and is the record released upon a valid
request
-Organization's official health record of patient
-Content varies from organization to organization
-No one-size fits all definition b/c laws and regulations governing the maintenance, content, and
documentation requirements of health record vary by practice, state, & fed law and regulations
Designated Record Set (DRS) - ANS HIPAA covered entity that A. are medical or billing
records; B. enrollment, payment, claims adjudication, and case or medical management record
systems; C. used in whole or part by or for covered entity to make decisions about individuals
-Encompasses more info than a LHR
Uniform Photographic Copies of Business & Public Records as Evidence Act (UPA) - ANS -
Supports transition from paper to electronic storage info
@COPYRIGHT ALL RIGHTS RESERVED PAGE 1 OF 15
, -Federal and State versions, states reproduction of any record retained in the regular course of
business & kept by process accurately & reproduce original in any medium.
Conditions of Participation (CoP) - ANS -The standards that govern providers receiving
Medicare and Medicaid reimbursements
-Require health records contain info to justify admission & continued hospitalization
The Joint Commission - ANS -Accredits healthcare organizations
-Requires health records be maintained and that content and documentation standards be
followed
Gaps & Omissions - ANS -Gaps are spaces left between entries in the paper health record
-spaces allow subsequent entries to be made in a space previous to an already existing entry--
prevent info from being added out of sequence
-Long periods of time without documentation can also hamper patient care when entered late
or not at all
Physician Order - ANS -one of most important pieces of documentation in health record
-Accuracy of medication orders is extremely important
-Order for admin of medicine such as narcotics & sedatives have time limits or stop orders-
automatically discontinue meds unless physician gives specific order to cont.
-written and verbal orders
-physician assistant and nurse practitioners have ability to give orders and prescribe meds
Verbal Orders - ANS -2 types
-Communicated in person or over the phone to individuals authorized to receive them
-high risk associated w/verbal orders = discouraged to use
-If provider is present he/she should document order instead of dictating to personnel
-Joint Commission established rule to "read back" orders
-All orders must be authenticated by provider who gave order
@COPYRIGHT ALL RIGHTS RESERVED PAGE 2 OF 15
