Legal Health Record Documentation

In the past, the terms health record and legal health record were used interchangeably, and the subtle nuances of these two terms provided little impact to the operations of a healthcare provider. The legal health record is the documents and data elements that a healthcare provider may include in response to legally permissible requests for patient information. Identifying the legal health record was simple when health records were primarily paper-based and included the contents of the paper health record in addition to diagnostic radiographic films or x-rays. During this time, the health record and the legal health record were one and the same. The legal health record became complicated when electronic health ­record technology was adopted and healthcare provider organizations moved from a strictly paper-based record to a more hybrid record model, and then to a fully electronic format since the health record became scattered and more information was available.

The current definition of the legal health record is complicated. Each healthcare organization must define what its legal health record contains. The legal health record is used to ensure compliance with laws and regulations, healthcare policies, accreditation standards, and any other requirements (HIMSS n.d.). Healthcare organizations with an EHR must determine what to do with health records that they receive from other healthcare providers. At one time, it was standard practice for a healthcare organization to incorporate another provider’s health record into the legal health record and release that documentation as part of the healthcare organization’s legal health record. Today, the healthcare organization should consult with legal counsel to assist with making a decision about whether or not to include another provider’s records in the legal health record. Some state laws dictate what can and cannot be included in the healthcare organization’s legal health record and, in many cases, the hospital’s attorney is in the best position to decide whether to include or exclude the records from other providers. For the EHR to be a legal health record and meet the requirements, several concepts need to be considered. These concepts include how documentation is actually created and signed by healthcare providers; how the documentation is managed and preserved; how the documentation impacts and interacts with the revenue cycle functions of billing and claims submission; and how the documentation is displayed both electronically to the user as well as in hard copy form, should the data be printed (HIMSS 2011). Once a healthcare organization defines its legal health record, necessary policies and procedures should be developed to formalize the healthcare organization’s approach to defining the health record. See chapter 8, Health Law, for more information about the legal health record.