CHAPTER 4

The Health Record

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Objectives

After reading this chapter, you should be able to:

• Define the medical record

• Determine the various uses and users of the medical record

• Delineate documentation guidelines for medical records

• Distinguish among the various medical record formats

• Outline the advantages and disadvantages of the electronic health record

• Discuss the elements of the national health information infrastructure

• Differentiate among the four parts of the HIPAA

• Interpret the provisions of the HIPAA

• Develop a HIPAA compliance plan for implementing an EHR

• Identify the various components found in the inpatient and outpatient ...

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