Certified Coding Associate (CCA) Practice Exam

The recommendation to alert hospital legal counsel of the practice is paramount when reports are changed too long after transcription, as it addresses potential legal risks and compliance issues. Changes made long after transcription could weaken the credibility and integrity of the medical records, which are vital for patient care and legal purposes. By involving legal counsel, the Health Information Management (HIM) director ensures that the facility is aware of potential liabilities and can take appropriate action to mitigate risks associated with these delayed changes. Legal counsel can provide guidance on how to adapt policies and procedures to uphold standards that meet legal and regulatory requirements.

The other choices, while important in their own right, do not directly address the potential legal implications. Stopping the practice of changing transcribed reports may be a logical action, but it does not engage with the legal complexities that arise from this issue. Developing a facility policy on acceptable draft times would help establish guidelines but doesn't offer immediate protection against legal repercussions. Conducting a verification audit might identify discrepancies or quality issues, yet it would not address the underlying legal concerns that arise from reports being altered after a certain period. Therefore, informing legal counsel is the most prudent recommendation in this scenario.