identify what information you believe should be included in the legal health rec
ID: 3908995 • Letter: I
Question
identify what information you believe should be included in the legal health record of a small pediatric clinic. Specifically, I want you to comment on why or why not the following information should be included. Your discussions should include technological, legal, and financial issues involved with the data storage of each type of data. I would like you to include in your discussion where and in what form each piece of data would be stored. Feel free to include other forms of information that I have not mentioned here.
1. Developed x-rays
2. Text messages
3. Emails
4. Printed information that the patient may have brought in (e.g. printouts from WebMD)
5. Photos of the patient's body (e.g. bruises, cuts, rashes, etc.)
Explanation / Answer
it should include everything staring from a ingle receipt of first time visit . three copies should be generated of every receipt (medicine receipt or test receipt) one copy should be given to patient , other should be given to labs and one should be kept in patients file for legal purposes if needed in future .
apart from that developed x rays should be kept at clinic for legal purposes and copy of that should be given to patient because whenever legal matters take place like mediclaims settlements dr. needs to send original xrays to insurance companies as a proof .
text messages are not valid for legal issues . they can be ignored . whatever written on prescription of dr. is valid .
Emails record is useful till ongoing process . for example when there is some kind of dispute .
nothis printed documents from webMD are not valid for legal purpose. they should be ignored . an proper tests should be done atclinic or on dr. recommendation. photos are not needed reports are enough . as photos can be morphed and fake photo creation is very easy hence it should be excluded while considering any legal matter .
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