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This chapter address the numerous documentation guidelines, documentation standards, and the sources of those standards.
The Objective is to understand the documentation standards and describe how medical staff bylaws, accreditation entities, and state and federal regulations influence the documentation practice standards of healthcare provider organization. You will define the legal health record and how it has changed as health care providers have more widely adopted electronic health record (EHR) technologies. You will identify and describe the documentation content of health records within different healthcare settings and you will understand the difference among consents, authorizations, and acknowledgments.
1. Define the following KEY TERMS:
Ambulatory surgery center (ASC)
Conditions for Coverage
Consent to treatment
Legal health record
Universal chart order
2. Internet activity: obtain state and federal regulatory documentation mandates as they relate to electronic health records.
a. Compare and contrast the mandates.
b. Identify state and federal level mandates the contradict and are in harmony with one another.
3. a. What influence do state and federal law and accrediting and licensing bodies have on the type of electronic health record system technology that is adopted by a healthcare provider organization?
b. What should healthcare providers consider putting into place to protect health record data to ensure that the health record integrity remains intact as well as the health record data is available so that he patient can be treated?
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