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    Chapter One

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    Tundex Concept
    The document discusses the legal aspects of health records in countries without clear laws on the topic, like Nigeria. It notes that health record policies are set by individual hospital management boards instead of national laws. It identifies 7 key legal aspects of health records, including the need to create and maintain them for each patient, ownership of records, patient access, confidentiality, consent requirements, and use in courts. Maintaining accurate health records serves important legal and non-legal purposes like documenting patient care, defending doctors and hospitals, and supporting billing and research.

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    Download as DOCX, PDF, TXT or read online from Scribd

    Chapter One

    Uploaded by

    Tundex Concept
    30 views1 page
    The document discusses the legal aspects of health records in countries without clear laws on the topic, like Nigeria. It notes that health record policies are set by individual hospital management boards instead of national laws. It identifies 7 key legal aspects of health records, including the need to create and maintain them for each patient, ownership of records, patient access, confidentiality, consent requirements, and use in courts. Maintaining accurate health records serves important legal and non-legal purposes like documenting patient care, defending doctors and hospitals, and supporting billing and research.

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    The document discusses the legal aspects of health records in countries without clear laws on the topic, like Nigeria. It notes that health record policies are set by individual hospital management boards instead of national laws. It identifies 7 key legal aspects of health records, including the need to create and maintain them for each patient, ownership of records, patient access, confidentiality, consent requirements, and use in courts. Maintaining accurate health records serves important legal and non-legal purposes like documenting patient care, defending doctors and hospitals, and supporting billing and research.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    30 views1 page

    Chapter One

    Uploaded by

    Tundex Concept
    The document discusses the legal aspects of health records in countries without clear laws on the topic, like Nigeria. It notes that health record policies are set by individual hospital management boards instead of national laws. It identifies 7 key legal aspects of health records, including the need to create and maintain them for each patient, ownership of records, patient access, confidentiality, consent requirements, and use in courts. Maintaining accurate health records serves important legal and non-legal purposes like documenting patient care, defending doctors and hospitals, and supporting billing and research.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    The legal aspect of health records should be best discusses in countries that have laws

    relating to the practice of health records.


    However, in countries like Nigeria, there is / are no law(s) guiding the practice of the
    profession. We rely on We rely borrowed and common laws, i.e. policies relating to the practice
    of, health records profession. These policies are made by each Hospital Management Board.
    Early, in the process of establishing Health Records Policies, it is important to review
    the laws and regulations as relating to Health Records which govern the institutions for
    which the health records system is being developed. Are view of the code of ethics of the
    National Medical Society and of other professional groups is also helpful
    The legal aspects of health records are grouped under the following heading:

    1. The need to create and maintain Health Record on each patient treated in the Hospital.
    2. Ownership of Health Records
    3. Patient's Right of Access to the Records the Patient's Right of access in the hospital
    4. Confidentiality of Health records
    5. The Consent/Authorization
    6. Uses of Health Records in the Court of Law
    7. Preservation/Retention of Health Records

    THE NEED TO CREATE AND MAINTAIN HEALTH RECORDS ON EACH PATIENT


    TREATED IN THE HOSPITAL
    The creation and maintenance of Health Records on each and every patient treated in an
    Hospital serves as an evidence of what the patient problem is and the treatment rendered and
    received. In other words, it serves as documentary evidence on the patient and how he or she
    was attended to in the hospital. The need to create and maintain Health Records on every
    patient treated in the hospital can be considered from both legal and non - legal point of view.

    1.1 UNDER LEGAL POINTS OF VIEW

    a. It serves as a source of defense for doctors and the hospital in case of litigation that may
    be brought against either of the doctors or the hospital
    b. It serves as documentary evidence for patient
    i. In case of claims
    ii. In case of settlement of bills
    iii. For compensation to the patient and other settlements

    1.2. UNDER NON - LEGAL POINTS OF VIEWN

    i. The primary purpose is for effective care of patient now and in the future
    ii. For statistical purposes
    iii. For evaluation of patients care
    iv. For research and planning
    v. For education and administration purposes etc.

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