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Commonly Asked Questions about Legal Documents for Healthcare

There are three types of medical records commonly used by patients and doctors: Personal health record (PHR) Electronic medical record (EMR) Electronic health record (EHR)
Typical medical records include: Patient identification, contact information, and date of birth. Billing and health insurance details. List of current and chronic ailments and diagnoses.
A legal health record (LHR) refers to documentation about a patients personal health information that is created by a healthcare organization or provider.
You can use an Advance Health Care Directive to say who you want to speak for you and what kind of treatments you want. These documents are called advance because you prepare one before healthcare decisions need to be made.
Some forms are still used in paper format, including for example, medical history surveys, consent forms, medical charts, letters, and memos. The medical office administrative assistant is responsible for accurate documentation and maintenance of patient medical office records.
Be clear, legible, concise, contemporaneous, progressive and accurate. Include information about assessments, action taken, outcomes, reassessment processes (if necessary), risks, complications and changes. Meet all necessary medico-legal requirements for documentation. Documentation of information | Australian Commission on Safety safetyandquality.gov.au nsqhs-standards safetyandquality.gov.au nsqhs-standards
Types of Medical Records EHR (Electronic Health Records) EHRs are comprehensive digital records that consolidate your health information in one secure location. PHR (Physical Health Records) Medical History Records. Medication Records. Immunization Records. Laboratory and Test Results. Progress Notes. Surgical Records.
Documentation typically reports why the patient was seen, what assessment or treatment was provided, clinical findings (e.g., diagnoses), and what (if any) treatment was recommended and provided in a way that justifies the assigned diagnosis and procedure codes (see Coding for Reimbursement).
Living wills and other advance directives are written, legal instructions regarding your preferences for medical care if you are unable to make decisions for yourself.