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Table of Contents
Introduction
Role of the Health Information Practitioner
Health Information Consultant Services
Practice Guidelines for LTC Health Information and Record Services
Record Systems, Organization and Maintenance
Audits and Quality Monitoring
Discharge Record Processing
Filing and Retrieval
Storage Systems
Retention
Destruction
Physical Security of Manual or Paper Records
Confidentiality and Release of Information
Coding and Reimbursement
Indexes and Registries
Minimum Statistical Reporting
Legal Documentation Standards
Purpose and Definition of the the Legal Medical Record
Legal Guidelines
Documentation in the Long Term Care Record
Checklist
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