Electronic Medical Records v. Legal Medical Records (Self-Study)

Course Description

The purpose of this program is to provide the participants with the following knowledge:

• The Medical Record, the designated record set and the legal medical record;
• Requirements for participation in Medicare and Medicaid;
• The Nuances of Electronic Health Records (EHR impacts on the LMR Definition); and
• Patient Portal, patient communication (e.g., texts, emails and portal communications) and the LMR definition.

Principles

• Medical Record Content
• HIPAA/HITECH Act
• Legal Medical Record

Syllabus

1. The right to privacy – where does it come from and how is it relevant to the medical record
2. Explanation of differences between the electronic medical record, designated record set, and legal medical record
3. Required content of medical record and medical necessity
4. Types of suits that are filed for violations, as well as the role of HIPAA and the HITECH Act
5. Texting and other types of communications and why it needs to be preserved

Instructor

Rachel V. Rose, Esq.