Medical Legal Aspects of Medical Records
Use this book to get a comprehensive overview of the medical records process. In any health care situation, records are made, and each situation presents its own unique aspects and challenges. This book covers most medical and hospital areas of specialty, and also includes chapters on dentistry, chiropractic care, nursing homes, medications and home care. It also covers forensic issues in medical records, including examination of records and medical records obtained as part of forensic examination or autopsies.Recent changes in legislation and technology have also changed the medical records process. The authors have designed this work to give extensive information on the HIPAA policies, standards initiatives, legal use of records, billing and coding, and computerization of records and record keeping systems and how they apply in forensic situations.This book is exceptionally valuable to all those in the legal profession or in law enforcement who deal with medical records on a regular basis. Generation and preservation of medical records Legal aspects of charting Creation and maintenance of records in the nursing process Charting systems Computerized records Billing and coding HIPPA regulations Standards Initiatives in medical records Obtaining, organizing and analyzing records Inpatient and outpatient specialty areas Tampering with medical records Forensic and autopsy records Forensic examination of medical records Attorney use of medical records