Legal health record
A legal health record (LHR) was a historically copy of the contents of the paper chart (often including imaging films and lab results). In recent years, electronic health record systems (EHRs) have changed this definition and complicated a healthcare legal organization’s ability to produce this business record.
Introduction
There currently are no standards in place to define or outline how to navigate this legal arena; and while organizations will find a wealth of information on the subject, there are too many variables, including an EHR system’s ability to effectively produce an entire LHR document. This means each organization is left to define the content of the LHR to best fit their system capabilities, legal environment and needed inclusion criteria and once that piece is accomplished it must also be recognized that the ongoing maintenance is much more complicated and time consuming. An effective change process must be in place to ensure the integrity of your documents. For example: If a workflow change is implemented (or any intended or unintended change for that matter), is someone ensuring how that change might have modified the countless number of reports generated via your EHR?
Experts acknowledge that an EHR decision could actually be a step backwards. In a paper world it was simple, but with hybrid systems at various stages of use, questions linger around items like electronic signatures and the metadata contained in EHR systems. And this remains the case, despite the number of years EHR systems have been around and the federal government promotion to accelerate adoption and meaningful use of such systems.
Implementation of an EHR system is a complex endeavor and reporting can often take a backseat to the recognized importance of how to get the data into the system! But organizations must seek balance to make certain this side of the equation is represented at planning meetings and receives appropriate time, training and communication to make sure the bumpy ride will be a little smoother for everyone.
References
- AHIMA e-HIM Work Group on the Legal Health Record. (2005). Update: Guidelines for Defining the Legal Health Record for Disclosure Purposes. Journal of AHIMA , 76 (8).
- Brandwein, A. (2008, August 25). Managing Hybrid Records: A Virtual Roundtable; Defining the Legal Medical Record in a Hybrid World...While Staying Sane, Too . Retrieved March 1, 2011, from Advance for Health Information Professionals: http://health-information.advanceweb.com/Article/Defining-the-Legal-Medical-Record-in-a-Hybrid-World.aspx
- Dolan, P. L. (2008, October 13). Is your EMR legal? A document can look like a medical record, but not meet the legal definition. Retrieved March 1, 2011, from amednews.com: http://www.ama-assn.org/amednews/2008/10/13/bisa1013.htm
- Dougherty, M., & Washington, L. (2008). Defining and Disclosing the Designated Record Set and the Legal Health Record. Journal of AHIMA , 79 (4), 65-68.
- Epic Systems Corporation. (2010, December). Release of Information. Retrieved March 5, 2011, from Epic Systems Corporation: https://sites.epic.com/epiclib/epicdoc/epicwise2010/epiccare%20link/setup%20and%20support%20guides/release%20of%20information.pdf
- OHSU Health Care System. (2010, July 6). Designated Record Set/Legal Health Record. Retrieved February 26, 2011, from OHSU Policies & Procedures : http://ozone.ohsu.edu/healthsystem/nursing/policy/display.cfm?id=892
Submitted by Karen Alexander
