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Which of the following should be included in the definition of the legal health record?

a. Incident reports
b. Insurance forms
c. Cancer registry data
d. History and physical

1 Answer

2 votes

Final answer:

The definition of the legal health record includes essential medical information such as history and physical, which documents a patient's health status and medical history. Incident reports, insurance forms, and cancer registry data are not part of the legal health record. the correct option is d. History and physical.

Step-by-step explanation:

The correct option for what should be included in the definition of the legal health record is d. History and physical. The legal health record is an official record that documents the care history and health status of an individual patient. This record includes a variety of documents, such as medical histories, diagnoses, treatments, and outcomes.

The history and physical (H&P) are core components of a patient’s health record as they provide essential medical information about the patient’s current and past health status as assessed by healthcare professionals. Incident reports are not part of the legal health record as they are internal documents used for quality improvement purposes. Insurance forms are administrative documents used for billing, not part of the clinical documentation.

User Richard Poole
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