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Legal Health Record Definition

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Legal Health Record Definition
University of Illinois at Chicago
A legal health record is “the documentation of healthcare services provided to an individual during any aspect of healthcare delivery in any type of healthcare organization” (AHIMA 2011). Legal health record definitions are diverse within each healthcare organization. The definition of the legal health record is established by the healthcare facility and should meet certain standards (AHIMA, 2011). The legal health record development gets more complicated with the conversion of technology. “Defining the legal health record becomes complex as organizations transition to EHRs with inherent capabilities that do not exist in paper-based records” (Fahrenholz & Russo 2013, p. 31).
It is important to have a well-defined definition of the legal health record. Every healthcare organization is responsible for defining its own legal health record and regulate them with the set requirements by the HIPAA privacy rule (AHIMA, 2011). It is also important to have a defined legal health record to help the hospital get funded, and to uphold and enhance its performance (Cottrell, 2006). The information in these records are crucial to every aspect in healthcare, involving delivery, reimbursement, education, and research (Fahrenholz Russo 2013, p. 45). If the legal health record is not clearly defined, then it could cause problems with …show more content…
Data elements are the basic unit of information that have a unique importance and subcategories that must be standardized and carried throughout the practices (Aspenden, et al., 2004). Specific codes should be recognized in all terminology sets to represent the data elements to ensure data comparability, which will allow all information systems to hold the data as a combined enterprise (Aspeden, et al.,
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