Legal Issues in Inappropriate Documentation of Medical Information and Solutions

You are the director of health information services at a tertiary-care hospital. You and the director of emergency room services are jointly responsible for reporting instances of communicable disease, child abuse, and cancer to the appropriate state authority. You have just completed an audit of your institution’s reporting mechanism and discovered that the reporting requirements are not consistently met. The audit could not definitively establish whether the reporting never occurred or occurred but was not documented in the patient’s health record. Discuss what legal issues are present and what approaches you should take to resolve this problem.

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