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 providers 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 consumers 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 organizations 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 RecordPaper 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