1. Discuss at least three purposes of the health record. How would you rank each of the purposes in terms ofimportance? How did you arrive at your decision? a. Best treatment of care. b. Decision making for care. c. Support documentation. This are all in order for rank of most important to least. Treatment of care and having that information can make for better results and that’s why a. is number one. 2.Why is the identification of patients and patient records so important to release of patient information andpatient care? 3.What are some examples of poor documentation practices in patient records? Why are these practices problematic? 4.Explain the problems of revisions to the patient record and the importance of controlling versions of the legal health record. 5.Describe the purpose of the Uniform Photographic Copies of Business and Public Records as Evidence Act (UPA) and the Uniform Electronic Transaction Act (UETA). How are they similar to one another?
1. IS the record complete and legible? 2. Is the patient’s name on each page? 3. Is there possible negligence action against the provider? 4. Remove addition materials not asked for. 5. Number each page. 6. Write an index of the contents. 7. Photocopy. 8. Personally deliver. 9. Never leave documents unattended or with someone else other than a representative of the court. 4
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- Spring '17
- Julie Wulf-Plimpton
- Electronic health record, Personal health record, Electronic Records