Legal Medical Documents

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Commonly Asked Questions about Legal Medical Documents

What is the legal document that allows individuals to state what medical treatment they want?

An advance directive is a legal document, prepared by you, that expresses what kind of medical care you want, or who is authorized to make decisions for you should you be unable to make or communicate your wishes. Health care advance directives include the following: A living will. Health care power of attorney.

What is a legal document in healthcare?

An LHR is an effective legal document if it does the following: Provides a detailed view of a patients health history and prognosis. Records caregivers observations and measurements. Provides evidence that a certain type of care was necessary and what standards were used to deliver it.

What is considered the legal medical record?

The Legal Medical Record is a subset of the Designated Record Set and is the record that will be released for legal proceedings or in response to a request to release patient medical records. The Legal Medical Record can be certified as such in a court of law.

What is a legal document that allows a person to specify the kinds of medical treatment he wishes to receive should the need arise?

Advance directives are written statements prepared ahead of time that allow caregivers to know of a patients wishes for treatment or that legally specify an alternate decision maker should the patient lose decision-making capacity. Advance directives sound like a good idea, but they are controversial.

What are the types of medical documents?

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.

What is a legal document that specifies the medical treatments a person would like to receive if incapacitated?

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.

What is a legal document that specifies the medical treatments?

A living will is a written document that specifies what medical treatment you would or would not want in the event you are in a terminal condition or a persistent vegetative state. A living will directs health care providers to cease or refrain from certain medical/surgical treatments.

What is the name of a legal document that instructs health care providers?

Advance directives and living wills are legal documents that give instructions to your family members, health care providers, and others about the kind of care you would want to receive if you can no longer communicate your wishes because you are incapacitated by a temporary or permanent injury or illness.