Using your workplace or practicum setting as your basis, you are to write a paper discussing the topic of the legal health record. The suggested length of the paper is 5-7 pages excluding title page, references, and any appendices.
In your paper, you should include the following.
- What constitutes the legal health record?
o Is this concept met within your facility? Why or why not?
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- For your organization or practicum setting, discuss (at a summary level) the flow of the patient record as it relates to the health information services department. At a minimum, the following should be included in your discussion:
o Data collection (including electronic and paper media, transcription services, quantitative/qualitative analysis, and chart completion);
o Health information access and use;
o Enterprise record management systems;
o Variables considered for active versus inactive health information;
o Record storage;
o Retention of data files including metadata and data stored in web applications; and
o Destruction of data/records.
NOTE: It may be beneficial to include some form of a flow diagram as an appendix to support your discussion
- Outline specifics on how the CHIMA Code of Ethics (and its associated guidelines) is demonstrate through the various processes in the flow of the patient record you have described. Review the grading rubric provided below for further details of the requirements of the paper and how marks will be assigned.