Question

In our efforts in understanding the legal requirements governing the content of health records such as; statutory, regulatory, accrediting, institutional, professonal guidelines.

explain and give examples of each of the five (5) sources of law which address the legal requirements.

Answer 1

Relevent Relevent Regulation, standard flows : Identify Answer. 1. commitee's clinical direction, the first health record & designated record step in definition the legal health record of de set is to determine what legal entities enforce re reowation. quidlines standar & lows on health record, uth these entities may have define a legal record in poper terms (eg, requiring a medication shet reiber then and elechonic medication administration, this definition must become the basis of the organization leges healthy record definition. 2. Determine Recorers created in the course of buisness & the second step is to determine whealthen the records are created in the provider or entity's ordinary course of business source system or raw dlater are the data from which interpretation, summaries and notes are derived - Record that from source system may be considered part of the legal record based on the content of the source system's record. - working notes used by a prorich to complete a final report are not considered part of the health record unless they are made available to other providing patient care. -) the determine factor in wheather information is to be considercel part of legen health recones is not where it resides of the format it takes. 3. Address Retention Requirement is - third step is determining the legal health record is ensure that component are retained appropriately. component in system disparate 7 storing CHR can cause mest problem. identity HILM professional mas and collaborate with IT professional and system urem o owner to define retention policies and practices.

4. considen How dota would be produced : the fourth step is defining the legal health record and designated record set is to determine how information proby be appropriately release. while it is easy to declare something such as an Ekly wave file as part of the legal health record set or must be designated record set, the organization must Consider how it will be reproduced, 5. Classify External Records is - The fifth step is detersiming how to classify external record recieve by the organization some state lours address how to classify external recorel; how eves, in the absence of state law, the esganization must determine if external records will be a part of the health recoses, - there is a school of thought that these external record were relied upon to make care decision they should be Include as part of the legal record However, including external records as peurt of the designated record set conel making them available in all approprate disclosure, Include disclosure in response to a subpoena. may accomplish the so process. ... Please read it I give me thumb up. same