Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:Introduction to Health Care and Public Health in the U.S.
Unit:Regulating Health Care
Lecture:The Role of Medical Records in U.S. Health Care
Slide content:The Health Record as a Legal Record Considered the business record for a health care organization Also a legal record Admissible in a court of law Substantiates quality of care provided 7
Slide notes:In any health care organization, the health record is considered the business record for the organization. As the business record of the organization, the health record holds key information for decision making, both administrative and clinical. The health record will be used for many purposes, such as analyzing the quality of care given a patient, processing claims for reimbursement, conducting research, and planning of resource needs. As such, it is also the legal record. Information documented in the health record can be used in a court of law as evidence to substantiate the quality of the treatment given to the patient. Therefore, health care organizations must consider the importance of clinical documentation as it relates to the legal health record. 7