Title: Duty to Maintain and Retain Health Record Information
Course: HIM 2012 Health Law > Section: Module 4 - Duty to Maintain and Retain Health Record Information

Introduction

Standards for record maintenance, content and documentation requirements have been established by a number of sources, which include federal and state laws, accrediting bodies and profession standard-setting organizations.  A specific healthcare organization must meet state licensure requirements in order to operate as a health care facility.  Licensure requires specific requirements for the content, format, retention and use of patient records.

Most healthcare organizations adhere to the record maintenance, content, and documentation requirements set forth by the Department of Health and Human Services, the Centers for Medicare and Medicaid Services, the Joint Commission or other accreditation bodies.  Accurate documentation in a health record should reflect the true, correct and specific description of care delivered for content and timing.  Documentation accuracy and completeness is the responsibility of the health care provider/author.

Objectives

Upon completion of this module, the student will be able to
- Describe the bodies that establish documentation and maintenance standards for the health record
- Identify the documentation principles that support a legally sound health record
- Identify the major content areas of the health record
- List the multiple purposes of the health record

Readings & Resources

Required reading:  Brodnik, Melanie.  Fundamentals of Law for Health Informatics and Information Management.  AHIMA Press.  Current edition. (Chapter 7, Chapter 8)

Optional:  Pozgar, George.  Legal Aspects of Health Care Administration.  Jones and Bartlett Learning.  Current edition.  (Chapter 11) Optional:  Servais, C.  The Legal Health Record.  AHIMA Press. Current edition
American Society of Law, Medicine and Ethics
American Health Information Management Association
Agency for Healthcare Research and Quality
Healthcare Information and Management Systems Society
American Medical Informatics Association

Assignments and Activities

- Read Chp. 7 and Chp. 8 in the Brodnik text

- Take the Module 4 Quiz
- Post on the Module 4 Discussion Board
- Post the Module 4 Internet Activity
- Continue working on the Health Law Electronic Portfolio (due in Module 10)