DEFINING THE MEDICAL RECORD: RELATIONSHIPS OF THE LEGAL MEDICAL RECORD, THE DESIGNATED RECORD SET, AND THE ELECTRONIC HEALTH RECORD.
| Autor: | Floyd PT, Oates JC, Acker JW, Warren RW |
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| Jazyk: | angličtina |
| Zdroj: | Perspectives in health information management [Perspect Health Inf Manag] 2021 Oct 01; Vol. 18 (4), pp. 1h. Date of Electronic Publication: 2021 Oct 01 (Print Publication: 2021). |
| Abstrakt: | Not so long ago, defining the "medical record" was simple. It was the paper chart-volume upon volume that captured the serial, dutifully recorded events of a person's health care at a hospital or physician's office. Entries were typically handwritten, dated and timed, and signed in ink with title (i.e., authenticated). Errors were easily identified by an authenticated strike-through. Similarly, the paper chart was synonymous with the legal medical record (LMR). In other words, a patient's paper chart was that patient's LMR by definition, even if critical data was omitted or irrelevant data was included. Fast-forward to 2021 and the use of technology for capturing the record of a patient's care. Technology has brought new challenges as well as successes. For example, pervasive and persistent mythologies include that 1) a patient's electronic health record (EHR) is the LMR, and 2) patient-specific EHR printouts to paper or disc-or displays on monitors-are necessarily equivalents to the paper chart of the 1980s. Neither are true. We now must define at the outset what is included in the LMR/designated record set to ensure the accuracy of what is retained and released. (Copyright © 2021 by the American Health Information Management Association.) |
| Databáze: | MEDLINE |
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