Identify whether your state (California) has a medical-legal manual prepared by the state Health Information Management Association.
If so, identify the cost of the manual and the section of the Table of Contents that addresses the content of the legal health record.
Include the following items in your submission:
Review your state statutes, rules, and regulations for requirements for content and retention of ambulatory records and hospital records. Include the specific statute or regulation.
Review your CMS rules and regulations for requirements for content and retention of ambulatory records and hospital records. Include the specific statute or regulation.
Access the Joint Commission Accreditation and Certification Manual and identify all standard sections for any reference to the health record content and documentation, authentication as well as completion requirements.