Defining the Legal Health Record
What constitutes an individual’s legal health record? Is a legal health record the same as HIPPA’s privacy law designated record set? It is necessary. According to AHIMA (2011), healthcare entities have and continue to grapple with the legalities of defining of an individual’s electronic health records (EHRs); with rapidly expanding healthcare organizations, increasing integrated delivery systems, and elaborate computer communications intra-network structures answering these questions continues to become more and more complex.
The Legal Health Record
According to AHIMA (2011, pp 44), “the legal health record (LHR) serves to identify what information constitutes the official business record of an organization for evidentiary purposes”. It documents any services provided to a patient during the course of stay: supporting provider care decisions, patient treatment responses, and documenting outcomes. Not only documenting clinical support, LHR’s support administrative functions: demonstrating adherence to policies and procedures; providing means for utilization review, and fulfilling necessary documentation for third party payers’ requirements.
By definition, LHRs must comply with standards established by the Centers for Medicare and Medicaid, state and federal guidelines, accrediting bodies and organizational policies and procedures. It is important to recognize legal health records are organizationally dependent; hence, specific documents contained within one organization’s LHR may not be the same for another. Thus, an organization’s LHR policies and procedures must “explicitly identify the sources, medium, and location of the individually identifiable data that it [...
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... it becomes readily apparent just how complex such a task can be. As stated by both AHIMA and KHA, much of today’s electronic data sources and information can fall into multiple patient care categories and much of it has yet to be defined. It’s all so overwhelming! Electronic health records, data capture, storage mediums have rapidly expanded to the point where we can barely contain it. Today data exists as raw data, aggregated data, metadata, forensic data, and big data. Protected health data consists of anything from of time/date stamps and audit trails to a patient’s history and physical. In my opinion, it becomes nearly impossible to establish rules for something, we have yet to establish….. Maybe if set definitive limits on “what is and what is not” health data, then it would be more likely possible to set rules and regulations to protect what is health data.
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