Chapter 1. Introduction to the legal Health Record
Chapter 2. Defining the Components of the Legal Health Record
Chapter 3. Electronic versus Legal Health Records
Chapter 4. Maintaining the legal Health Record
Chapter 5. Electronic Health Records and the Legal Process
Chapter 6. Summary and Conclusions
Appendix of Resources
 Complete Medical Record in Hybrid HER Environment: Task Force Report
 Core Data Sets for the Physician Practice Electronic Health Record
 Correcting and Amending Entries in a Computerized Patient Record
 Defining the Designated Record Set
 Definition of the Health Record for Legal Purposes
 Disaster Planning for Health Information
 Document Imaging as a Bridge to the HER
 Documentation Requirements for Acute Care Inpatient Record
 E-Discovery and HIM: How Amendments to the Federal Rules of Civil Procedures Will Affect HIM Professionals
 E-Discovery: preparing for the Coming Rise in Electronic Discovery Requests
 The EHR’s Impact on Health Information Management (HIM) Functions
 Electronic Documentation Management as a Component of the Electronic Health Record
 Foundational Concepts of the legal HER
 Getting Off to a Good Start: Tips from the Launch of Two HIM Systems
 Guidelines for Defining the Legal Health Record for Disclosure Purposes (Update)
 Guidelines for Electronic Health Record Documentation to Prevent Fraud
 Helping Consumers Select PHRs: Questions and Considerations for Navigating an Emerging Market.
 HIPAA on the Job: A Primer on Encryption
 In Emerging Data Networks, a Role for HIM: Regional Data Exchange Presents New Questions for Fundamental HIM Issues
 Implementing Electronic Signatures
 Keep It Clean: Optimizing EHRs Starts with Ensuring Data Quality
 The Legal Process and Electronic Health Records
 Maintaining a Legally Sound Health Record—Paper and Electronic
 The New Electronic Discovery Civil Rule
 A Quick Scan of Bar Coding
 Recommended Regulations and Standards for Specific Healthcare Settings
 Record Disclosure and the HER: Defining and Managing the Subset of Data Disclosed upon Request
 Redisclosure of Patient Health Information
 Retention of Health Information (Update)
 The Strategic Importance of Electronic Health Records Management: Checklist for Transition to the HER
 Understanding the HER System Functional Model Standard
 Unwrapping Data Standards
 Using Test Vignettes to Assess HER Capabilities