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Documentation of services provided by a health care provider to a patient
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∙ 8y ago
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Why should a recording in the medical record never be erased or abliterated?
The medical record is a legal document.
Which name do you use for a medical record legal name or the name on the insurance card?
Your legal name.
What actions should be taken if you identify an error in a patients medical record?
No deletions should be made, as the medical record is also a legal document. But an amending notation should be made and added to the medical record.
What is the purpose of a medical chart?
to serve as both a medical and legal record of an individual's clinical status, care, history, and caregiver involvement.
Are medical records a legal document?
No, not generally. Many medical records, and the notations made in medical files, are unsigned and un-witnessed. They may be introduced as EVIDENCE and used in a case but generally, in and of themselves, they are not considered "legal" documents.
What is the legal health record?
The legal health record is a collection of documentation that serves as the official record of a patient's medical history and treatment received at a healthcare facility. It includes information such as medical diagnoses, treatment plans, progress notes, test results, and medication orders. The legal health record is used for continuity of care, billing, and legal purposes.
Is it legal to destroy medical records?
Medical records are a complicated issue. Who owns them? The clinic or hospital that maintains the record, or the person about which the record is kept? Most states now say the clinic or hospital owns the actual physical record, and the person owns the information. This gives you the right to see your records and to decide who has access to them. In order to destroy the record a Judge would have to issue an order to the keeper of the record to expunge it. You would need a compelling reason as to why the record should be destroyed. It is currently not legal to have a medical record destroyed without a court order.
Is it legal to have someone rewrite the medical record even if they did not see the patient and shred the original?
No, it is not legal to have someone rewrite a medical record without having seen the patient and then shred the original. This would be considered falsifying medical records, which is illegal and unethical. Any alterations or amendments to a medical record should be accurately documented and maintained for legal and ethical reasons.
How electronic health records and reform affect medical billers and coders.?
EHR software is used by medical coders and billers to justify financial reimbursement from insurance companies and maintain a legal record of medical events.
What are the importance of medical record keeping?
The importance of medical record keeping is keeping a treatment record of a patient that allows medical professionals to know the patient's past
What is the medical term meaning record of the eardrum?
Tympanogram is the medical term for a record of the eardrum.
Is marijuana is legal in medical use?
Medical marijuana is legal with a prescription from your doctor.
