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Follow four steps to lighten your legal load

HIM Connection, December 19, 2005

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Defining your legal record may sound like an easy job-but this is often far from the truth, says Kelly McLendon, RHIA, president of consulting firm Information Evolution Management in Titusville, FL. It's important to do so because defining the legal health record can help streamline HIM job functions.

Take the following four steps to define your legal record:

1. Build a team. Put together a team that includes both HIM and information technology (IT) staff. It is essential to involve both departments because each group will recognize different components you should consider when formalizing your definition.

   For example, the IT department may question why HIM wants a document management system with duplicate information in a clinical repository. HIM staff will need to explain that keeping everything in one record helps them do their jobs more efficiently.

   No clinical system or EHR will meet all HIM requirements. Once you build your team, work backwards to define your legal record. Arriving at a definition is actually the last step.

    

2. Break down your records. Locate all of the pieces of your current medical record. For example, where are labs and progress notes located? It's likely that different electronic systems will store different components of your record. List all of the documents and data types that could be in a medical record.

    

3. Create a document matrix. Once you determine where all your record components "live," create a list or matrix of questions that you can answer about each document to determine whether it will be part of your legal health record.

   A hospital can have 200-3,000 document types for inpatient visits alone. If you have 1,000 document types (e.g., cumulative labs, history and physicals, etc.), ask 10-12 questions about each document, McLendon says. For example, ask, "Does this form support document nonrepudiation?" In other words, once a clinician signs a document, can you be sure the document can't be changed?

    

   • What is the media type(s) used for each document, data, and report?
   • Is the media secure (i.e., access and failure security)? List mechanisms such as redundant array of inexpensive disks, storage area networks, back-up, fail-over storage located off-site, etc.
   • How are documents/data/reports stored in the media? What preparation, indexing, quality control, and reconciliation are performed?
   • What indexing/meta-data (i.e., definitional data that provides information about other data managed within an application) are kept for each document/data/report type?
   • Can documents/data/reports be destroyed on a defined retention schedule?

    

4. Examine your results. Once you answer your matrix of questions for each document type, you will have all of the necessary information at your fingertips. Now examine how these pieces of information fit together to make a record.

   At this stage, be proactive and carefully check for holes. If you find yourself in court, a sharp lawyer will look for ways to attack the credibility of your data. As the custodian of the record, be aware of all the different places records can live.

Editor's note: This article was adapted from Electronic Health Records Briefing.

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