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. Legal process and electronic health records administrative law rules and regulations developed by various administrative bodies empowered by congress this falls under the umbrella of public law process controls and checks exist to ensure the reliability and accuracy of the record policies and procedures exist to protect the record . Medical records documentation of patient care in the legal health record from a risk management perspective the legal health record is generally the information used by the patient care team to make decisions about the treatment of a patient policies must dictate what is and is not an acceptable amendment the following describes . Legal medical record standards policy no 9420 legal medical record standards purpose to establish guidelines for the contents maintenance and confidentiality of patient medical policies made by a person who has knowledge of the acts events opinions or diagnoses relating or her protected health medical record information that . The legal health record regulations policies and guidance explains from a record managers perspective how to create and execute projects that result in medical records that are better organized and increasingly offer better legal defensibility
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