This person can issue a court order

This concept of data management is concerned with the tine period during which data is created.

A policy should define exactly what this form of the record is, as it may stand as evidence in court.

These include emergency room notes, history and physicals, discharge summaries, progress notes, and procedural notes

If a court order is not properly complied with, the custodian of records may be found in THIS and receive jail time or fines?

The form of a health record that is the legal business record of the organization and serves as evidence in lawsuits or other legal actions.

This concept of data management is concerned with the time period after information has been created

Per policy, this includes both paper and electronic documents.

This document includes demographics and other pertinent patient information, as is part of the legal record

A patient may file a complaint where?

Where employee can find out what must be included in all legal health records

This is the combined practices of HIM, IT, and HI that affect how data and documentation combine to create a single business record.

This policy states that each person access the health record only as needed for their job duties. This concept is called?

These documents signed by the patient or his/her representative must be in the record if a procedure has been done.

This may be in the form of testimony or court documents.

This signed document is often required by HIPAA to view a patient's health record

This is the reliability and effectiveness of data for its intended uses, including evidentiary value.

Per policy, this person investigates alleged breeches of the health record or policy noncompliance?

The therapy notes and administered medications in the record are called?

These include laboratory and radiology results on the record.

Legal requests should be served during normal business hours to this person.

This type of data management is concerned with accuracy and integrity.

Medical record policies are designed to be in compliance with this acronym for the Health Insurance Portability and Accountability Act that was passed by Congress in 1996.

These are required for any procedure or test that has been performed.

this document is found in the record and summarizes a visit for an inpatient.