Legal health record comprises of the documentation of the health information of a patient, which is created by a healthcare organization. This important record is used in the healthcare organization as a business record, and will be made available when a patient or legal services request for it. The LHR or legal health record is required for peer reviews and peer reviews and medical claims review. Whether paper or electronic, medical records must be maintained in a legally sound way or they may end up being challenged as invalid in a court of law. The legal health record is generally used when replying to formal medical record request for legal purposes.
What does a patient record contain?
- Healthcare facility’s record
- Pharmacy records
- Physician records
- Diagnostic test results or therapies
- Records from other care providers
- Patient’s own personal health record
- Administrative and financial data and documents
The records may be in different media types such as diagnostic images, voice files, video, and email. The components of a legal health record could vary based on how each healthcare organization defines it. Typically, it is the documentation of various medical services provided to a patient in any type of healthcare organization. The legal health record is significant in the following ways:
- Serves as the healthcare organization’s business and legal record.
- Serves as documentary proof of the services provided, which is useful as legal testimony regarding the plaintiff’s injury or illness, his/her response to treatments, and decisions of caregivers.
- It supports the decisions made regarding the patient’s care.
- It supports the medical claim submitted to insurers.
According to ahima.org, the following things must be considered when defining the legal health record.
- Consider all the applicable standards, regulations, and laws.
- Next, determine whether the records are created in the provider/entity’s ordinary course of business.
- Consider retention requirements: The medical records must be retained properly in keeping with federal and state requirements.
- How data would be produced: The requested healthcare information must be appropriately released. Important questions in this context are whether the source system can print or download the data to a CD; how it will be accessed by the requesting entity; and whether it is in an understandable format and is easily accessible.
- How external records are to be classified: Some state laws give direction on classifying external records. if state law is absent, the healthcare facility must determine whether the external records should be a part of the patient’s health record.
When it comes to disclosure of medical information, the following steps can be considered.
- Develop and maintain a list of documents and data that comprise the legal health record. Determine whether data that is not document-based such as diagnostic images, digital photography, video and email will be part of the legal health record.
- Have a single repository for legal retention requirements.
- Health information that is not used or not requested must be returned to the patient or disposed of in keeping with the organization’s destruction procedures.
- In collaboration with clinicians, develop procedures to identify external information that has been used in patient care. The identified information must be placed in the patient record. In the record, consideration should be given to filing or indexing the external information under a separate tab/section. It is important to review state statutes that may require inclusion of external information.
- Written policies and procedures can be developed, and staff training provided for clinical users that address the use of external information.
- Identify the records that patients can access and amend under state and federal laws and regulations.
- Apply HIPAA’s pre-emption standards where individuals’ rights to access and amend are not the same under other federal/state laws and regulations.
Before the advent of the electronic health record, the legal health record was simply the contents of a paper medical chart. However, with more healthcare facilities adopting electronic health records, and with the increasing use of medical apps for patient monitoring and tracking data on various electronic media forms, it is becoming increasingly complex to define and create a legal health record. Now that EHRs are used for medical claims review purposes, healthcare providers must ensure that their EHR is a legal record and meets all statutory, regulatory, and professional requirements for clinical as well as business purposes. It must be appropriately designed and used to ensure adherence to federal and state rules as well as institutional requirements, and any additional certification standards applicable to each organization.