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The Complete Legal Guide to Healthcare Records Management

Author : Cherilyn G. Murer

Publisher : McGraw-Hill Companies

Page : 808 pages

File Size : 17,83 MB

Release : 2000

Category : Business & Economics

ISBN :

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Book Description

While much has changed in the delivery of healthcare in this country, what has not changed is the importance of maintaining and managing medical records. All healthcare organizations must keep complete medical records to comply with Federal and state laws, to minimize exposure to malpractice liability and to ensure that quality care is given to patients.With more systems crossing state lines and an increase in centralized medical records departments, The Complete Legal Guide to Healthcare Records Management becomes a valuable resource to the professional who handles records from multiple geographic locations. Users of this resource will be in a position to maintain or improve their records management systems and to protect themselves from regulatory compliance violations and malpractice liability.The Complete Legal Guide to Healthcare Records Management is an all-in-one resource and reference for healthcare professionals in a variety of settings. The comprehensive state-by-state format allows organizations who deliver care in diverse geographic locations to understand and account for variations in state requirements on record keeping.Topics covered in The Complete Legal Guide to Healthcare Records Management: -- Records defined -- general discussion and definitions of Federal and state laws -- Ownership issues of medical records -- general ownership, physician/provider conflict -- Records to keep -- Why must you keep records? -- Time requirement for record-keeping -- The electronic record and special problems with advancing technology -- Storing medical records -- Correcting medical records -- Disclosure of records -- such as drug and alcohol abuserecords, communicable disease information -- Dealing with court orders and subpoenas -- Participation in Medical Research -- Disposal of medical records -- Healthcare business records -- what are they and do you keep them?The Complete Legal Guide to Healthcare Records Management is a must-have for anyone in the healthcare industry who comes in contact with healthcare records!



The Computer-Based Patient Record

Author : Committee on Improving the Patient Record

Publisher : National Academies Press

Page : 257 pages

File Size : 21,21 MB

Release : 1997-10-28

Category : Medical

ISBN : 030957885X

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Book Description

Most industries have plunged into data automation, but health care organizations have lagged in moving patients' medical records from paper to computers. In its first edition, this book presented a blueprint for introducing the computer-based patient record (CPR). The revised edition adds new information to the original book. One section describes recent developments, including the creation of a computer-based patient record institute. An international chapter highlights what is new in this still-emerging technology. An expert committee explores the potential of machine-readable CPRs to improve diagnostic and care decisions, provide a database for policymaking, and much more, addressing these key questions: Who uses patient records? What technology is available and what further research is necessary to meet users' needs? What should government, medical organizations, and others do to make the transition to CPRs? The volume also explores such issues as privacy and confidentiality, costs, the need for training, legal barriers to CPRs, and other key topics.



Registries for Evaluating Patient Outcomes

Author : Agency for Healthcare Research and Quality/AHRQ

Publisher : Government Printing Office

Page : 385 pages

File Size : 22,25 MB

Release : 2014-04-01

Category : Medical

ISBN : 1587634333

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Book Description

This User’s Guide is intended to support the design, implementation, analysis, interpretation, and quality evaluation of registries created to increase understanding of patient outcomes. For the purposes of this guide, a patient registry is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes. A registry database is a file (or files) derived from the registry. Although registries can serve many purposes, this guide focuses on registries created for one or more of the following purposes: to describe the natural history of disease, to determine clinical effectiveness or cost-effectiveness of health care products and services, to measure or monitor safety and harm, and/or to measure quality of care. Registries are classified according to how their populations are defined. For example, product registries include patients who have been exposed to biopharmaceutical products or medical devices. Health services registries consist of patients who have had a common procedure, clinical encounter, or hospitalization. Disease or condition registries are defined by patients having the same diagnosis, such as cystic fibrosis or heart failure. The User’s Guide was created by researchers affiliated with AHRQ’s Effective Health Care Program, particularly those who participated in AHRQ’s DEcIDE (Developing Evidence to Inform Decisions About Effectiveness) program. Chapters were subject to multiple internal and external independent reviews.



Improving the Quality of Health Care for Mental and Substance-Use Conditions

Author : Institute of Medicine

Publisher : National Academies Press

Page : 528 pages

File Size : 23,73 MB

Release : 2006-03-29

Category : Medical

ISBN : 0309133661

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Book Description

Each year, more than 33 million Americans receive health care for mental or substance-use conditions, or both. Together, mental and substance-use illnesses are the leading cause of death and disability for women, the highest for men ages 15-44, and the second highest for all men. Effective treatments exist, but services are frequently fragmented and, as with general health care, there are barriers that prevent many from receiving these treatments as designed or at all. The consequences of this are seriousâ€"for these individuals and their families; their employers and the workforce; for the nation's economy; as well as the education, welfare, and justice systems. Improving the Quality of Health Care for Mental and Substance-Use Conditions examines the distinctive characteristics of health care for mental and substance-use conditions, including payment, benefit coverage, and regulatory issues, as well as health care organization and delivery issues. This new volume in the Quality Chasm series puts forth an agenda for improving the quality of this care based on this analysis. Patients and their families, primary health care providers, specialty mental health and substance-use treatment providers, health care organizations, health plans, purchasers of group health care, and all involved in health care for mental and substanceâ€"use conditions will benefit from this guide to achieving better care.



Guide to Clinical Documentation

Author : Debra Sullivan

Publisher : F.A. Davis

Page : 301 pages

File Size : 22,87 MB

Release : 2011-12-22

Category : Medical

ISBN : 0803629974

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Book Description

Develop the skills you need to effectively and efficiently document patient care for children and adults in clinical and hospital settings. This handy guide uses sample notes, writing exercises, and EMR activities to make each concept crystal clear, including how to document history and physical exams and write SOAP notes and prescriptions.







How to Practice Academic Medicine and Publish from Developing Countries?

Author : Samiran Nundy

Publisher : Springer Nature

Page : 475 pages

File Size : 22,69 MB

Release : 2021-10-23

Category : Medical

ISBN : 9811652481

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Book Description

This is an open access book. The book provides an overview of the state of research in developing countries – Africa, Latin America, and Asia (especially India) and why research and publications are important in these regions. It addresses budding but struggling academics in low and middle-income countries. It is written mainly by senior colleagues who have experienced and recognized the challenges with design, documentation, and publication of health research in the developing world. The book includes short chapters providing insight into planning research at the undergraduate or postgraduate level, issues related to research ethics, and conduct of clinical trials. It also serves as a guide towards establishing a research question and research methodology. It covers important concepts such as writing a paper, the submission process, dealing with rejection and revisions, and covers additional topics such as planning lectures and presentations. The book will be useful for graduates, postgraduates, teachers as well as physicians and practitioners all over the developing world who are interested in academic medicine and wish to do medical research.