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Designated record sets include medical records, billing records, payment and claims records, health plan enrollment records, case management records, as well as other records used, in whole or in part, by or for a covered entity to make decisions about individuals.
Which is the appropriate method for correcting data in a medical record? Remove the item with the incorrect data, and then create a new form with the correct information.
When an error is made in a medical record entry, proper error correction procedures must be followed.Draw line through entry (thin pen line).Initial and date the entry.State the reason for the error (i.e. in the margin or above the note if room).Document the correct information.
Release of information (ROI) is the process of providing access to protected health information (PHI) to an individual or entity authorized to receive or review it.
The patient's legal name, date of birth, gender, Social Security number, address, telephone number, guarantor, subscriber, or next-of-kin are key identifying elements that assist in establishing the proper individual.