Your outside reading for this week discusses the similarities and differences between the LHR (legal health record) and the DRS (designated record set). For this assignment, you will access an excel file that contains some of the documents or files that are to be reviewed. See above link for template. This is not an exhaustive list. For each element, you will indicate the primary source of the document. For example, if your institution has an electronic capture of consent forms, then the source would be the EHR documentation system. But if consent forms are still done via a paper form, then you would indicate that the source is paper. Examples of the primary sources are given below. This is not a complete list, so if your institution has a different source for the information, you are free to use that.
Examples of Primary Sources
Nursing documentation system
EHR documentation system
PACS (Picture Archiving and Communication System)
Admitting documentation system
You will also indicate if the document/file is part of the Designated Record Set or the Legal Health Record. Part of the assignment includes formatting the file in a way that is user friendly to the reader. This may include regrouping some of the items, using shading or borders to help the end user find information, or you may need to add additional columns to capture the information you feel is important (although additional columns are not required). If your entries do not fit into the template column width, please format so that the entry is wrapped in the cell.
The comment section can be utilized for any clarification you may wish to make.
In addition, you will research the retention requirements for these documents. In some areas, there are no specific guidelines. It is up to the institution to determine the retention period. If you cannot find a specific time period, either check with your institution, or use your best judgement and indicate your reasoning in the comment section.
State Medical Record Laws. Table A-7. HealthIT. https://www.healthit.gov/sites/default/files/appa7-1.pdf
Retention and Destruction of Health Information. AHIMA. 2013. (http://library.ahima.org/PB/RetentionDestruction#.V9LcAzW8JsU
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