Health Information Management

Assignment Task

Instructions:

Using your workplace or practicum setting as your basis, you are to write a paper discussing the topic of the legal health record.

In your paper, you should include the following.

a) What constitutes the legal health record?

• Is this concept met within your facility? Why or why not?

b) 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:

• Data collection (including electronic and paper media, transcription services, quantitative/qualitative analysis, and chart completion);

• Health information access and use;

• Enterprise record management systems;

• Variables considered for active versus inactive health information;

• Record storage;

• Retention of data files including metadata and data stored in web applications; and

• Destruction of data/records.

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