Health Information Management

Understand how versioning can affect your legal health record

HIM-HIPAA Insider, March 10, 2009

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In the context of the EHR, versioning is the ability to capture and track serial changes in the electronic documents, data, or reports. Documents, data, and reports are not necessarily static within a dynamic EHR because they evolve as clinicians add, change, or remove information.

Logging changes to record information and matching the changes to clean, organized "versions" is more important so that when you look at the record, you have the ability to view the most recent note, as well as all previous versions. Without version management, there is no way to reconstruct which clinicians knew what information at what point during a patient’s course of care.

Versions also create snapshots of the documents at a given point in time. This information is useful not only in legal proceedings but also in any activity that requires tracking the progression of information throughout a patient’s encounter.

Editor’s note: This article was excerpted from HCPro’s book The Legal Health Record Companion: A Case Study Approach by Deborah A. Adair, MPH, MS, RHIA, and Karen B. Griffin.



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