Based on the committees 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. The designated record set is generally broader than the legal health record because it addresses all protected health information along with business information unrelated to patient care the legal health record is generally the information used by the patient care team to make decisions about the treatment of a patient. The health care provider or health plan must respond to your request if it created the information it must amend inaccurate or incomplete information if the provider or plan does not agree to your request you have the right to submit a statement of disagreement that the provider or plan must add to your record. The legal health record copy and paste guidelines ahima 2009 him webinar series 3 notes comments questions toolkit overview content 1 him professional responsibilities. Legal process and electronic health records the custodian of an electronic health record ehr has the same concerns as the custodian of a paper health record when the record becomes involved in the legal process
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