Based on the committee’s clinical direction, the first step in defining the legal health record and designated record set is to determine what legal entities enforce relevant regulations, gu
Based on the committee’s clinical direction, the first step in defining the legal health record and designated record set is to determine what legal entities enforce relevant regulations, guidelines, standards, or laws on health records. Although these entities may have defined a legal record in paper terms (e.g., requiring a medication sheet rather than an electronic medication administration record), their definitions must become the basis for the organization’s legal health record definition.
Committee Reports (of patient-specific care decisions)
Ethics committee or tumor board, if deciding on a course of treatment for an individual patient
Note: Documentation of findings could be reported in the patient’s medical record. Other legal privileges may apply to these records.
designated record set only
Administrative and Financial
Super bills/encounter forms
Remittance advice
Case management records
designated record set only
Secondary/Administrative and Statistical
Tumor registries data
QI/QM reports and abstracts
Statistical data
Committee minutes (not patient-specific treatment related)
neither
Fundamentals of the Legal Health Records )
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