Question

Analyze the Fundamentals of the Legal Record AHIMA Brief, In your own words answer the following. What constitutes a legal health record? Who defines a legal health record? What difficulties are associated with a legal health record?

Answer 1

The legal health record serves to identify what information constitutes the official business record of an organization for evidentiary purposes. The legal health record is a subset of the entire patient database. The elements that constitute an organization's legal health record vary depending on how the organization defines it. Following points should be kept in mind while preparing legal health records -

1.Identify Relevant Regulations, Standards, and Laws

2. Determine Records Created in the Course of Business

3. Address retention requirement.

4. Consider how data while be produced

5. Classify external records

Legal health care records are created by health care organization with the help of physician

Difficulties associated with legal health records include error in documentation, breeching of personal health records , vulnerability to malpractice claims.