02 — Capability · BC-1880.10
Legal Health Record
Keep each patient's legal health record complete, accurate, timely and defensible, by defining what it contains, driving incomplete records to completion and correcting entries the proper way. Enterprise retention schedules are records management.
- Medical Records
- Record Completion
- Health Record Integrity
In scope
- Legal record definition and designated record set
- Record completion and deficiency tracking
- Amendments, corrections, scanning and indexing
- Record integrity audits
Out of scope
- Retention schedules and disposition (see BC-790.10)
- Patient identity and duplicate medical record numbers (see BC-1810.20)
- Assigning diagnosis and procedure codes (see BC-1840.20)
Realized by · 0
- No product in the catalog yet.
Used in · 2
Build it · 1
Decomposes into · 5
- BC-1880.10.10Legal Record DefinitionDefine which documents and data make up the legal health record and the designated record set, in every system that holds them, and the retention period health record law sets for each part.
- BC-1880.10.20Chart Deficiency TrackingFind records missing signatures or documentation after a visit or discharge, prompt clinicians to finish them, and report delinquency.
- BC-1880.10.30Record Amendment & CorrectionCorrect errors and handle patient requests to amend their record through a controlled process that preserves the original entry.
- BC-1880.10.40Document Imaging & IndexingScan paper and outside documents into the health record and file each one to the right patient and encounter.
- BC-1880.10.50Record Integrity ReviewAudit the record for misfiled documents, copied text and other documentation integrity problems, and fix what is found.