1. The legal health record is the documentation of healthcare services provided to an individual during any aspect of healthcare delivery in any healthcare organization. According to American Health Information Management Association (AHIMA), "the legal health record serves to identify what informa...
1. The legal health record is the documentation of healthcare services provided to an individual
during any aspect of healthcare delivery in any healthcare organization. According to American
Health Information Management Association (AHIMA), "the legal health record serves to
identify what information constitutes the official business record of an organization for
evidentiary purposes. (Haugen, Tegen, and Warner, 2011). The subset of an entire patient base is
the legal health record; hence, components that form an organization's legal health record differ
depending on its intent.
Therefore, some organizations may find it complicated to reply to a demand to pull a legal
medical record because the legal health record documentation can physically be in individual,
multiple paper-based, or electronic systems. (Brinda and Wapola, 2013). Data in EHRs is usually
accumulated in numerous systems, hindering the capability to briefly pull together the record for
legal health records or designated records. Thus, an institution's legal health record definition
must explicitly specify the origin, medium (paper, images, video, audio, and such), and the
location of the individually identifiable data. (Brinda and Wapola, 2013).
2. Hospitals are typically a critical environment due to the focus on making expedient clinical
decisions, timely evaluation, and stabilizing patients. According to the National Institute of
Health, the intake process has a high propensity to become flawed due to the intensity and
sometimes chaos created by the need to render timely and quality care" (Hakimzada et al., 2008).
Factors such as a disproportionate staff-to-patient ratio, language barriers, and time pressures can
contribute to a lack of accuracy in patient registration.
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller THEEXCELLENCELIBRARY. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $9.49. You're not tied to anything after your purchase.
