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Start at the beginning when defining the legal health record

HIM Connection, October 23, 2006

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Defining any term in the healthcare industry is a treacherous process. The industry is constantly changing to reflect innovations in medicine, while various stakeholders jumpstart disjointed efforts to modify healthcare processes and explain those decisions. For example, several professional organizations are currently trying to define the electronic health record (EHR) and the electronic medical record (EMR). Some use these terms interchangeably, whereas others use them to describe different systems. This inconsistency trickles down to the provider level.

The situation is no different with defining the legal health record. Fortunately, however, you are in the position to create your own custom legal health record definition-one that reflects the culture at your facility and helps fulfill its mission.

There are several definitions that various organizations currently use. However, when defining the term "legal health record," note that a generalized definition won't fit every healthcare organization. Although such a definition is a good place to start, it's only a beginning.

To draft a definition that works for your facility, first understand why you need one. A solid definition will help you

• reflect the scope of information that needs proper management (i.e., what to include)
• release or disclose the appropriate portions of the record as required and in accordance with the law
• ensure and maintain data integrity so you can correctly respond when users need the legal health record (e.g., storage, retention, and safeguards)

Although federal, state, and possibly local laws will provide an initial framework on which to base your legal health record definition, ultimately it is up to your organization to fine tune the definition to suit its distinct purpose. Remember that the primary purpose of the health record is to serve as a communication tool for caregivers to provide ongoing care to the patient. It is also used for a variety of other reasons, including research, reimbursement, outcomes measurement, and education. How your organization wishes to collect and maintain its patient data should play a role in defining the legal health record, and you'll need to decide whether to maintain components of research, e-mail communications, between patient and provider, and health information from outside your organization (e.g., information from other hospitals) as part of your legal health record. These decisions will contribute to your decision.

Stay tuned for next week's HIM Connection. We'll share six steps to take in order to make sure you address the law as well as your own facility documentation when defining your legal record.

Editor's note: This article was adapted from the brand new HcPro book The Legal Health Record Companion: A case study approach. This book was co-written by Deborah A. Adair, MPH, MS, RHIA, the director of health information at Massachusetts General Hospital, and Karen B. Griffin, the manager of health information at Brigham and Women's Hospital in Boston, MA.

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