Historically, the definition of the legal health record was fairly straightforward: the contents of the paper chart (together with radiology films or the results of other imaging studies) formed the healthcare provider’s legal business record. Patients had limited interest in or access to the information contained in their records.

However, with the advent of various electronic media, implementation of the Health Insurance Portability and Accountability Act (HIPAA), the Internet, and the consumer’s enhanced role in compiling their health information, the definition of the legal health record has become more complex. The need to ensure information is accessible for its ultimate purposes, regardless of the technologies employed or users involved remains. Therefore, the definition of the legal health record must be continuously reassessed in light of new technologies, users, and uses.

Unfortunately there is no one-size fits all definition as the laws and regulations governing the content vary by practice setting and state. However, there are common principles that can be followed in creating a definition.

According to the American Health Information Management Association (AHIMA), each organization must define the content of the legal health record to best fit its system capabilities and legal environment. Considerations for the content of the legal health record should include ease of access to different components of patient care information, guidance from the medical staff and the organization’s legal counsel, community standards of care, federal regulations, state law and regulations, standards of accrediting agencies, and the requirements of third-party payers.

Legal health records must also meet accepted standards as defined by applicable Centers for Medicare and Medicaid Services Conditions of Participation, federal regulations, state laws, and standards of accrediting agencies such as the Joint Commission on Accreditation of Healthcare Organizations, as well as the policies of the healthcare provider.

For the health record to be authenticated or deemed admissible as evidence, the following four basic principles must be met:

• Documented in the normal course of business (following normal routines)
• Kept in the regular course of business
• Made at or near the time of the matter recorded
• Made by a person within the organization with knowledge of the acts, events, conditions, opinions, or diagnoses appearing in it

In order to understand the scope of what constitutes a legal health record AHIMA convened several e-HIM® workgroups in 2005 to research and review various aspects. The outcome reports, “Update: Guidelines for Defining the Legal Health Record for Disclosure Purposes,” “Update: Maintaining a Legally Sound Health Record—Paper and Electronic,” and “The Legal Process and Electronic Health Records” are available free at www.ahima.org/infocenter/ehim and support for the workgroups was funded by grants to the Foundation of Research and Education (FORE).

In addition AHIMA provides distance and live education:

• “EHR and the Legal Health Record” audio seminar available on CD and Archived Webcast
• “Turning Theory into Practice: The Next Step for e-HIM®” a one-day seminar that includes information on how to define the legal EHR
• Additional education is being developed and will be available at www.ahima.org



The University of Miami School of Nursing and Health Studies has received over $675,000 from the Florida Department of Education’s SUCCEED Florida grant program. These state funds will enable the school to increase the number of nurses and nursing instructors in the region.

“The nursing shortage is directly related to the shortage of nursing instructors,” said Nilda P. Peragallo, DrPH, RN, FAAN, dean of the school. “By assisting the University of Miami to prepare nurse educators as well as nurses, the State of Florida is helping to build a stronger nursing workforce, which will result in better care for Florida communities.”

This is the second year that the UM School of Nursing and Health Studies has received SUCCEED Florida funding. This year’s grant allocates $451,439 to support students in the school’s Education Certificate Program and $226,604 to support students in the Accelerated BSN program. The University of Miami is one of seven private institutions statewide to receive SUCCEED Florida funding.

The six-month Education Certificate Program enables expert practitioners to acquire the skills and knowledge they need to become clinical nursing instructors.

The Accelerated BSN program enables individuals who already hold undergraduate degrees to earn a baccalaureate in nursing and enter the workforce within twelve months.



Cedars Medical Center Selects 3 Employees for New Emerging Leadership Program

Over a period of several months, under the leadership and direction of Beth Brill, HCA East Florida Division HR Vice President, and Charlene Ingwell, RN, MSN, Director of Workforce Development and Organizational Development, a group of Chief Nursing Officers and Human Resource leaders from the HCA East Florida Division developed a program to address future succession planning. The program, known as The Emerging Leadership Program, was designed to grow, groom, and develop future leaders and began in August 2006. In total, there are 12 interns in the program, representing 5 of the 13 hospitals and 2 from IRL in the East Florida Division.

Top Row (l-r) : Avril March, Daphne Charles, Pamela Gordon.
Bottom Row (l-r) : Gary Mcclelland, Kim Mccartney, Jorge Toledo

Once the curriculum was developed, the Program was advertised internally to employees in all East Florida Hospitals. Immediately, employees started sending in their applications. At Cedars, the applicants were asked to participate in panel interviews with Associate Vice Presidents, Nursing Directors, and Staff Nurses. At Cedars Medical Center, 3 RN’s were accepted into the program – Kim Mccartney, RN, MSN, Gary McClelland, RN, and Jorge Toledo, RN.

The Emerging Leaders have each been paired up with a preceptor who will guide them through the program for the next year. Kim’s preceptor is Daphne Charles,RN, Nursing Director for one of Cedars’ Orthopedic Units. Gary’s preceptor is Avril March,RN, MSN, Nursing Director for one of Cedars’ Acute Care Units. And Jorge’s preceptor is Pamela Gordon,RN, Nursing Director for Cedars’ inpatient Dermatology Unit. Over the next year these preceptors will play a significant role in the success of Cedars’ Emerging Leaders. Mentors and interns meet with the CNO every other week to monitor the progress of the intern, plan for upcoming experiences and projects, and support the leadership roles of these individuals. “It is a well-worth investment of our time to commit to the development of these nursing leaders. This model of formal training and experience can only benefit the interns and the institutions in which they will work, once the program is completed,” says, Silvia Stradi, RN, MSN, Chief Nursing Officer at Cedars Medical Center.



13 students recently graduated from Jackson Memorial Hospital’s School of Radiologic Sciences. Alfredo Bringas received the JRCERT Valedictorian award as well as the Academic Excellence and the Outstanding Achievement awards. Sherrell Hill and Cesar A. Alvarez were the recipients of the Mallinkropt Clinical Excellence award.

First Row (l-r): Sherrell Hill, Alba L. Pulido, Alfredo A. Bringas, Renee Richards, Tyrone Rudio and Christopher Cendan.
Second Row (l-r): Jean Ronold Booz, Ricardo Garcia, Romona Smith, Cesar A. Alvarez, Mark S. Martin, Roby M. Chelagiri and Jim Kelly, pose for a picture after the 2007 School of Radiologic Sciences graduation at Jackson Memorial Hospital.

Sponsored by the Jackson’s Radiology Services/Diagnostic Imaging Division, the Radiologic Sciences program has been educating students since 1955. The program provides cutting-edge instrumentation, techniques and clinical applications. The mission of the program is to provide comprehensive didactic and clinical education to enable graduates to acquire the entry-level skills required of a Radiologic Technologist.

(l-r) Tometra Meadows, B.S., R.T., Clinical Coordinator, Department of Radiology; Alfredo Bringas, winner of the JRCERT Valedictorian; Clinical Excellence Award Winners Cesar Alvarez and Sherrell Hill; and Courtney Glenn, M.S.M., R.T., radiography program director, JHS School of Radiologic Sciences, pose for a picture after the 2007 School of Radiologic Sciences graduation at Jackson Memorial Hospital.



HCA is proud to announce their second course of the Nursing Emerging Leadership Program starting in October, 2007. This eighteen month program is an ongoing commitment to provide leadership for the development and education of clinical nurse managers/directors as well as providing a succession plan for employees retiring from management positions within the division. The Emerging Leaders Program (ELP) is designed to recruit nurses with high leadership potential from South Florida as well as from within HCA East Florida Division.

This program provides leadership skills specific for the healthcare industry through didactic and hands on training. A mentor will be provided for each intern in the program. The Emerging Leadership Program educates future managers/directors to a high level of competency which provides success and job satisfaction within their own work environment. The comprehensive evidence based curriculum includes communication, human resource management, financial and regulatory management, systems thinking, interpersonal effectiveness, personal mastery, and caring.