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The Legal Health Record
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Book Synopsis Medical Records and the Law by : William H. Roach
Download or read book Medical Records and the Law written by William H. Roach and published by Jones & Bartlett Learning. This book was released on 2006 with total page 613 pages. Available in PDF, EPUB and Kindle. Book excerpt: Published in conjunction with the American Health Information Management Association (AHIMA), the Fourth Edition of Medical Records and the Law is once again the ideal text for programs in HIM as well as a valuable reference resource for health professionals and those in the legal profession. Providing a useful resource to those in the legal profession, it addresses the substantial changes brought about by HIPAA and the growth of electronic health record systems and electronic data networks, retaining and updating the discussion of state laws affecting the use and disclosure of health informat
Author :Agency for Healthcare Research and Quality/AHRQ Publisher :Government Printing Office ISBN 13 :1587634333 Total Pages :396 pages Book Rating :4.5/5 (876 download)
Book Synopsis Registries for Evaluating Patient Outcomes by : Agency for Healthcare Research and Quality/AHRQ
Download or read book Registries for Evaluating Patient Outcomes written by Agency for Healthcare Research and Quality/AHRQ and published by Government Printing Office. This book was released on 2014-04-01 with total page 396 pages. Available in PDF, EPUB and Kindle. Book excerpt: This User’s Guide is intended to support the design, implementation, analysis, interpretation, and quality evaluation of registries created to increase understanding of patient outcomes. For the purposes of this guide, a patient registry is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes. A registry database is a file (or files) derived from the registry. Although registries can serve many purposes, this guide focuses on registries created for one or more of the following purposes: to describe the natural history of disease, to determine clinical effectiveness or cost-effectiveness of health care products and services, to measure or monitor safety and harm, and/or to measure quality of care. Registries are classified according to how their populations are defined. For example, product registries include patients who have been exposed to biopharmaceutical products or medical devices. Health services registries consist of patients who have had a common procedure, clinical encounter, or hospitalization. Disease or condition registries are defined by patients having the same diagnosis, such as cystic fibrosis or heart failure. The User’s Guide was created by researchers affiliated with AHRQ’s Effective Health Care Program, particularly those who participated in AHRQ’s DEcIDE (Developing Evidence to Inform Decisions About Effectiveness) program. Chapters were subject to multiple internal and external independent reviews.
Author :Committee on Improving the Patient Record Publisher :National Academies Press ISBN 13 :030957885X Total Pages :215 pages Book Rating :4.3/5 (95 download)
Book Synopsis The Computer-Based Patient Record by : Committee on Improving the Patient Record
Download or read book The Computer-Based Patient Record written by Committee on Improving the Patient Record and published by National Academies Press. This book was released on 1997-10-28 with total page 215 pages. Available in PDF, EPUB and Kindle. Book excerpt: Most industries have plunged into data automation, but health care organizations have lagged in moving patients' medical records from paper to computers. In its first edition, this book presented a blueprint for introducing the computer-based patient record (CPR). The revised edition adds new information to the original book. One section describes recent developments, including the creation of a computer-based patient record institute. An international chapter highlights what is new in this still-emerging technology. An expert committee explores the potential of machine-readable CPRs to improve diagnostic and care decisions, provide a database for policymaking, and much more, addressing these key questions: Who uses patient records? What technology is available and what further research is necessary to meet users' needs? What should government, medical organizations, and others do to make the transition to CPRs? The volume also explores such issues as privacy and confidentiality, costs, the need for training, legal barriers to CPRs, and other key topics.
Author :William Kelly McLendon Publisher :Amer Health Information Management ISBN 13 :9781584262589 Total Pages :120 pages Book Rating :4.2/5 (625 download)
Book Synopsis The Legal Health Record by : William Kelly McLendon
Download or read book The Legal Health Record written by William Kelly McLendon and published by Amer Health Information Management. This book was released on 2011 with total page 120 pages. Available in PDF, EPUB and Kindle. Book excerpt: Rev. ed. of: Legal health record / Cheryl E. Servais; Neil S. Olderman and Kelly A. Trahan, technical editors. [1st]. c2008.
Book Synopsis Medical Records and the Law by : William H. Roach Jr.
Download or read book Medical Records and the Law written by William H. Roach Jr. and published by Jones & Bartlett Publishers. This book was released on 2006-04-18 with total page 613 pages. Available in PDF, EPUB and Kindle. Book excerpt: Published in conjunction with the American Health Information Management Association (AHIMA), Medical Records and the Law is the ideal text for programs in HIM as well as a valuable reference for health and legal professionals. The Fourth Edition features an expanded discussion of state laws affecting the use and disclosure of health information and the substantial changes brought about by HIPAA and the growth of electronic health record systems. It also discusses the highly complex interplay of federal and state laws as well as the challenging area of how patient information may be used in connection with medical research involving human subjects.
Author :Deborah A. Adair Publisher :Hcpro, a Division of Simplify Compliance ISBN 13 :9781578398812 Total Pages :0 pages Book Rating :4.3/5 (988 download)
Book Synopsis The Legal Health Record Companion by : Deborah A. Adair
Download or read book The Legal Health Record Companion written by Deborah A. Adair and published by Hcpro, a Division of Simplify Compliance. This book was released on 2006 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: Practical advice and policy guidance to manage patient records for legal scrutiny By most definitions, a health record is the set of documents used to provide optimum patient care and document the patient's progress across the continuum of care, generate a bill for appropriate reimbursement, and conduct audits and research. Whether on paper, in a hybrid format, or completely electronic, the medical record is the industry Bible--the source from which all other records and documents are generated. But medical records also serve as legal documents. At any time, a court may require a record as part of a legal proceeding, and you must be ready to provide it. The Legal Health Record Companion: A case study approach is a hands-on resource tool that shows you how to define and develop health records that meet legal requirements. You'll learn how to use the health record appropriately and efficiently--from the legal point of view--as well as from the more familiar patient safety and common-sense perspective. Developed from field experience Authors Deborah Adair and Karen Griffin use actual case scenarios from Massachusetts General Hospital and Brigham & Women's Hospital in Boston to demonstrate how to put responsibility into best practice when developing sound and reliable legal health records. You will learn how to document a true "reflection" or evidence of a patient's true status create a legal health record definition that works for your facility protect the legal health record maintain the legal health record in a manner that ensures that the most accurate, well-organized, and accessible health information is available for the care and treatment of the patient employ best-practice operational standards The authors also include sample policies your can customize for your organization, a pertinent question and answer section, and a glossary of frequently used terms. What makes it a "legal" record? It's not easy to define what comprises a legal health record. Every organization has its own procedures for which documents are added to its records. Forms and policies differ, even within the organization. Professional organizations suggest record-keeping practices for clinical staff. Regulatory agencies add another level of record criteria. The HIPAA privacy and security rules place mandates on what defines a record. Ultimately it is your organization's responsibility to define its legal health record. That definition will change and you will continue to massage the definition as long as you have to--especially as you convert to electronic health records--to maintain the integrity of information you keep.
Book Synopsis Health Records and the Law by : Donna K. Hammaker
Download or read book Health Records and the Law written by Donna K. Hammaker and published by Jones & Bartlett Learning. This book was released on 2018-08-16 with total page 420 pages. Available in PDF, EPUB and Kindle. Book excerpt: This fifth edition of Health Records and the Law addresses the substantial changes brought about by the Health Insurance Portability and Accountability Act (HIPAA) and the growth of network information systems, with discussion of state laws affecting the use and disclosure of patient data. The text also discusses the highly complex interplay of federal and state privacy laws. In addition to the considerable new material concerning HIPAA and its regulations, this edition addresses the challenging area of how patient information may be used in connection with medical research and the impact that the Health Information Technology for Economic and Clinical Health (HITECH) Act is having on public health monitoring and surveillance.
Book Synopsis Improving the Quality of Health Care for Mental and Substance-Use Conditions by : Institute of Medicine
Download or read book Improving the Quality of Health Care for Mental and Substance-Use Conditions written by Institute of Medicine and published by National Academies Press. This book was released on 2006-03-29 with total page 528 pages. Available in PDF, EPUB and Kindle. Book excerpt: Each year, more than 33 million Americans receive health care for mental or substance-use conditions, or both. Together, mental and substance-use illnesses are the leading cause of death and disability for women, the highest for men ages 15-44, and the second highest for all men. Effective treatments exist, but services are frequently fragmented and, as with general health care, there are barriers that prevent many from receiving these treatments as designed or at all. The consequences of this are seriousâ€"for these individuals and their families; their employers and the workforce; for the nation's economy; as well as the education, welfare, and justice systems. Improving the Quality of Health Care for Mental and Substance-Use Conditions examines the distinctive characteristics of health care for mental and substance-use conditions, including payment, benefit coverage, and regulatory issues, as well as health care organization and delivery issues. This new volume in the Quality Chasm series puts forth an agenda for improving the quality of this care based on this analysis. Patients and their families, primary health care providers, specialty mental health and substance-use treatment providers, health care organizations, health plans, purchasers of group health care, and all involved in health care for mental and substanceâ€"use conditions will benefit from this guide to achieving better care.
Book Synopsis Medical Records and the Law by : William H. Roach Jr.
Download or read book Medical Records and the Law written by William H. Roach Jr. and published by Jones & Bartlett Learning. This book was released on 2006-04-18 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: Published in conjunction with the American Health Information Management Association (AHIMA), Medical Records and the Law is the ideal text for programs in HIM as well as a valuable reference for health and legal professionals. The Fourth Edition features an expanded discussion of state laws affecting the use and disclosure of health information and the substantial changes brought about by HIPAA and the growth of electronic health record systems. It also discusses the highly complex interplay of federal and state laws as well as the challenging area of how patient information may be used in connection with medical research involving human subjects.
Book Synopsis Medical Records and the Law by : William H. Roach
Download or read book Medical Records and the Law written by William H. Roach and published by Aspen Publishers. This book was released on 1998 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: The Third Edition of this highly successful textbook addresses the issues associated with managed care and advances in computer technology that have occurred since the last edition. New legal issues arise when information is integrated and widely available in different electronic formats to a growing number of players in the health care delivery system. The legal issues surrounding technological advances in computer-based patient records, electronic links between patients and providers, telemedicine, community-wide information systems, and access to patient record information are addressed. The implications of new Federal regulation of the confidentiality of health care information, an overview and discussion of state and Federal regulation of managed care, provisions governing electronic payment claims contained in the Health Insurance Portability and Accountability Act and their impact on the transmission of other forms of health care information will all be features of the third edition of Medical Records and the Law. An Instructor's manual is available.
Book Synopsis Medical Records and the Law by : William H. Roach
Download or read book Medical Records and the Law written by William H. Roach and published by Aspen Publishers. This book was released on 1985 with total page 346 pages. Available in PDF, EPUB and Kindle. Book excerpt: Published in conjunction with the American Health Information Management Association (AHIMA), the Fourth Edition of Medical Records and the Law is once again the ideal text for programs in HIM as well as a valuable reference resource for health professionals and those in the legal profession. Providing a useful resource to those in the legal profession, it addresses the substantial changes brought about by the Health Insurance Portability and Accountability Act and the growth of electronic health record systems and electronic data networks, retaining and updating the discussion of state laws affecting the use and disclosure of health information. This book also discusses the highly complex interplay of federal and state health information privacy laws. The Fourth Edition addresses the challenging area of how patient information may be used in connection with medical research involving human subjects. Features: With the evolution in how health information is created, stored, retrieved, used, and transmitted, the need for protection has resulted in new and comprehensive regulation in the form of HIPAA, and this book addresses its voluminous privacy, security, identifier, code set, and transactions regulations. Medical Records and the Law, Fourth Edition provides the tools healthcare providers and government agents need, at all levels, given the increased focus on accountability for the quality of health care. This book focuses on, the reduction of errors and rapid access to electronic health records as essential and fundamental parts of successful quality improvement efforts. Book jacket.
Book Synopsis Legal Aspects of Health Information Management by : Dana C. McWay
Download or read book Legal Aspects of Health Information Management written by Dana C. McWay and published by Cengage Learning. This book was released on 1997 with total page 328 pages. Available in PDF, EPUB and Kindle. Book excerpt: This textbook introduces the legal principles pertinent to the health care field. Written by a lawyer, the book addresses the principles of liability, patient records requirements, confidentiality and informed consent, medical records as evidence, HIV information, and the security of computerized patient records. The second edition adds a chapter on health care fraud and abuse. Annotation c. Book News, Inc., Portland, OR.
Book Synopsis Electronic Health Records and Medical Big Data by : Sharona Hoffman
Download or read book Electronic Health Records and Medical Big Data written by Sharona Hoffman and published by Cambridge University Press. This book was released on 2016-12-07 with total page pages. Available in PDF, EPUB and Kindle. Book excerpt: This book helps readers gain an in-depth understanding of electronic health record (EHR) systems, medical big data, and the regulations that govern them. It analyzes both the shortcomings and benefits of EHR systems, exploring the law's response to the creation of these systems, highlighting gaps in the current legal framework, and developing detailed recommendations for regulatory, policy, and technological improvements. Electronic Health Records and Medical Big Data addresses not only privacy and security concerns but also other important challenges, such as those related to data quality and data analysis. In addition, the author formulates a large body of recommendations to improve the technology's safety, security, and efficacy for both clinical and secondary (such as research) uses of medical data.
Book Synopsis Capturing Social and Behavioral Domains and Measures in Electronic Health Records by : Institute of Medicine
Download or read book Capturing Social and Behavioral Domains and Measures in Electronic Health Records written by Institute of Medicine and published by National Academies Press. This book was released on 2015-01-08 with total page 374 pages. Available in PDF, EPUB and Kindle. Book excerpt: Determinants of health - like physical activity levels and living conditions - have traditionally been the concern of public health and have not been linked closely to clinical practice. However, if standardized social and behavioral data can be incorporated into patient electronic health records (EHRs), those data can provide crucial information about factors that influence health and the effectiveness of treatment. Such information is useful for diagnosis, treatment choices, policy, health care system design, and innovations to improve health outcomes and reduce health care costs. Capturing Social and Behavioral Domains and Measures in Electronic Health Records: Phase 2 identifies domains and measures that capture the social determinants of health to inform the development of recommendations for the meaningful use of EHRs. This report is the second part of a two-part study. The Phase 1 report identified 17 domains for inclusion in EHRs. This report pinpoints 12 measures related to 11 of the initial domains and considers the implications of incorporating them into all EHRs. This book includes three chapters from the Phase 1 report in addition to the new Phase 2 material. Standardized use of EHRs that include social and behavioral domains could provide better patient care, improve population health, and enable more informative research. The recommendations of Capturing Social and Behavioral Domains and Measures in Electronic Health Records: Phase 2 will provide valuable information on which to base problem identification, clinical diagnoses, patient treatment, outcomes assessment, and population health measurement.
Book Synopsis The Medical Record as Evidence by : Elliott Oppenheim
Download or read book The Medical Record as Evidence written by Elliott Oppenheim and published by ATOM Press. This book was released on 2012-08 with total page 1001 pages. Available in PDF, EPUB and Kindle. Book excerpt: Elliott B. Oppenheim practiced family medicine and emergency medicine for nearly eighteen years before attending law school and obtaining a master's degree in health law. He attended Occidental College (BA 1969), The University of California at Irvine (MD 1973), Detroit College of Law at Michigan State University (JD 1995), and Loyola University School of Law, Chicago (LL.M. Health Law 1996). He has written extensively about medical malpractice litigation, the Emergency Medical Treatment and Active Labor Act, and spoliation of evidence in medical negligence litigation and continues to write on medical-legal subjects. Dr. Oppenheim has been active in the field of medical negligence litigation for almost twenty-five years. He heads coMEDco, Inc., a national medical-legal consulting firm as President and CEO. Dr. Oppenheim also teaches health law. SUMMARY TABLE OF CONTENTS Chapter 1. Admissibility of Medical Records Chapter 2. The Recording Sequence Chapter 3. Why There Must Be a Record Chapter 4. Spoliation Chapter 5. Confidentiality and Privilege Chapter 6. Discovery and Trial Techniques This book is a pdf made from a high quality scan of the original.
Book Synopsis Electronic Health Records by : Margret Amatayakul
Download or read book Electronic Health Records written by Margret Amatayakul and published by . This book was released on 2004 with total page 452 pages. Available in PDF, EPUB and Kindle. Book excerpt: "This book discusses the elements of EHR implementation in a clear, chronological format from planning to execution. Along the way, readers receive a solid background in EHR history, trends, and common pitfalls and gain the skills they will need for a successful implementation."
Book Synopsis Key Capabilities of an Electronic Health Record System by : Institute of Medicine
Download or read book Key Capabilities of an Electronic Health Record System written by Institute of Medicine and published by National Academies Press. This book was released on 2003-07-31 with total page 36 pages. Available in PDF, EPUB and Kindle. Book excerpt: Commissioned by the Department of Health and Human Services, Key Capabilities of an Electronic Health Record System provides guidance on the most significant care delivery-related capabilities of electronic health record (EHR) systems. There is a great deal of interest in both the public and private sectors in encouraging all health care providers to migrate from paper-based health records to a system that stores health information electronically and employs computer-aided decision support systems. In part, this interest is due to a growing recognition that a stronger information technology infrastructure is integral to addressing national concerns such as the need to improve the safety and the quality of health care, rising health care costs, and matters of homeland security related to the health sector. Key Capabilities of an Electronic Health Record System provides a set of basic functionalities that an EHR system must employ to promote patient safety, including detailed patient data (e.g., diagnoses, allergies, laboratory results), as well as decision-support capabilities (e.g., the ability to alert providers to potential drug-drug interactions). The book examines care delivery functions, such as database management and the use of health care data standards to better advance the safety, quality, and efficiency of health care in the United States.
