HIM 115 Chapter 8 – Flashcards

verification of records validity ( that is , it is the record of the individual in question and it is what it purports to be), and therefore, its reliability and truthfulness as evidence; also as security mechanism to validate the identity of a user in an electronic system

the genuineness of a record, that is is what it purports to be; information is authentic if proved to be immune from tampering and corruption

a record that is made and kept in the usual course of business, at or near the time of the event recorded

an element of a legally defensible health record; the health record is not complete until all its parts are assembled and the appropriate documents are authenticated according to medical staff by laws

a group of records maintained by or for a covered entity encompassing medical records and billing records about individuals and enrollment, payment, claims adjudication in part, by or for the covered entity to make decisions about individuals

an agency that develops standards for healthcare organizations and certifies healthcare organizations on the basis of adherence to those standards

the form of a health record that is the legal business record of the organization and serves as evidence in lawsuits or other legal actions: what constitutes an organizations legal health record varies depending on how the organization defines it

a patient-identifying directory that serves as a link to the patient record or information, facilitates patient identification, and assists in maintaining a longitudinal patient record from birth to death

a mechanism for storing records, providing for timely retrieval, and establishing the length of time that various types will be retained by the healthcare organizations

a statutory enactment that places time limits on certain claims

federal statute that makes electronic transactions as enforceable as paper transactions, removing barriers to electronic commerce and increasing trust associated with electronic business transactions

Federal statute, with state versions, that makes admissible as evidence the reproduction of an y record that has been retained in the regular course of business and kept by a process that accurately reproduces the original in any medium; supports the transition from from paper to electronic storage of information.