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GENERAL CLINICAL DOCUMENTATION AND …

HIMAA Practice Brief 1 GENERAL DOCUMENTATION & Information requirements 1 of 42 December 2006 HIMAA PRACTICE BRIEF NO1 GENERAL CLINICAL DOCUMENTATION AND INFORMATION requirements DECEMBER 2006 HIMAA Practice Brief 1 GENERAL DOCUMENTATION & Information requirements 2 of 42 December 2006 TABLE OF CONTENTS INTENTION AND RECOMMENDED DOCUMENTATION HEALTH RECORD TABLE 1: Authentication of paper-based Legibility of Availability of the Accessibility of the Correction of Information and Version Requests for Change in Accordance with Freedom of Information ..14 TIMELINESS OF DOCUMENTATION / INFORMATION APPROPRIATE CONTENT OF DOCUMENTATION / Continuity of patient Legal Accountability Research, education and evaluation of ACCURATE AND OBJECTIVE DOCUMENTATION PRACTICE TABLE 2: CLINICAL DOCUMENTATION Medical Practitioner.

HIMAA Practice Brief 1 – General Documentation & Information Requirements 5 of 42 December 2006 V.1.0 4.0 GLOSSARY The following is a list of terms, associated definitions and concepts used in this

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