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Medical Records Basics

Understand the legal obligations and duties arising from the use and retention of medical records.

It may seem the term 'medical records' is easy to define and that the professional and legal obligations related to their creation, use, and retention are rather straightforward. However, it is not so simple once one considers the responsibilities mandated by the highly regulated health care industry that is creating and maintaining those records and when rights to their ownership and access are asserted. In reality, the term 'medical records' is not a one-size-fits-all definition but rather encompasses varying duties and obligations that are dependent upon the patient, their illness, and type of provider. This material will help those who create and use medical records on a regular basis understand the legal obligations and duties arising from their use and retention. It will explore what constitutes a medical record and who may assert claims to their access and ownership. A discussion on best practices will be valuable to ensure proper standards and compliance are met. Case studies will be used to further illustrate when problems may arise and how planning and training may reduce the likelihood of an adverse event occurring. It is critical that individuals and employers who regularly work with medical records understand what is necessary to meet these obligations and anticipate issues that may arise in their use.

71 minutes
Course Exam
Certificate of Completion
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Why Lorman?

Over 34 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.

Agenda

Introduction

  • What Constitutes a Medical Record?
  • The Good and Bad With Electronic Medical Records
  • Confidentiality vs. Privacy vs. Security: Are They the Same?

Types of Medical Records and Their Components

  • Hospital and Facility Records
  • Physician and Other Clinical Records
  • Ancillary Providers Records

Organization and Oversight of Medical Records

  • What Constitutes an Adequate Medical Record?
  • Requirements to Be Able to Attest to a Medical Record
  • Best Practices in Organization and Oversight

Access and Ownership of Medical Records

  • Who Owns the Medical Records?
  • Who May Access the Medical Records?
  • When May I Withhold Releasing Medical Records?

Let's Put It All Together

  • Landmines, Trapdoors, and Other Unexpected Problems
  • Case Studies
  • Conclusion/Questions
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Why Lorman?

Over 34 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.

Credits

OnDemand Course

This course was last revised on March 31, 2021.

Call 1-866-352-9540 for further credit information.

  • AHIMA 1.0 including Informatics, Analytics, and Data Use 1
     
  • This program has been approved for 1.0 continuing education units for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). Granting prior approval from AHIMA does not constitute endorsement of the program content or its program sponsor.
     

This program does NOT qualify, nor meet the National Standard for NASBA accreditation.

MP3 Download

This program does NOT qualify, nor meet the National Standard for NASBA accreditation.

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Why Lorman?

Over 34 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.

Faculty

Patrick D. Souter

Patrick D. Souter

Gray Reed & McGraw LLP

  • Of Counsel, Gray Reed & McGraw LLP
  • Representation of physicians, hospitals, and ancillary providers in operational, regulatory, and administrative matters
  • Board certified in health care law by the Texas Board of Legal Specialization
  • Adjunct professor of health care studies at Baylor University School of Law and frequent speaker to national and local health care organizations
  • Recognized as a leading health care lawyer in Texas by Chambers & Partners USA (2020) and selected by his peers for inclusion in Woodward/White, Inc.'s The Best Lawyers in America in the field of health care law (2019 - 2021)
  • Frequent author of books and articles for the American Health Law Association (AHLA) and American Bar Association (ABA) including co-authoring the AHLA’s Representing Physicians, 4th edition and the ABA’s Physician Law Evolving Trends and Hot Topics (2017- 2020 editions) and What is ... Medical Staff Peer Review?
  • Frequent speaker on physician, hospital, and other provider issues
  • Member of the American Bar Association, State Bar of Texas, American Health Law Association, American College of Healthcare Executives, and Health Care Compliance Association
  • LL.M. degree in health law, Hofstra University; J.D. degree, Baylor University School of Law; M.B.A. degree in health services management, University of Dallas
  • Can be contacted at 214-954-4135, [email protected] or 1601 Elm Street, Suite 4600, Dallas, Texas 75201
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Product ID: 408410
Published 2021
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