When is a document considered part of a legal health record?
A patient's medical record is the historical account of the patient/provider encounter and serves as a legal document for use in legal proceedings. A patient's medical record must contain all the necessary documentation to support the services rendered and billed, as well as the medical necessity of those services.
Why are personal health records required to be available to patients?
A patient's medical record is the historical account of the patient/provider encounter and serves as a legal document for use in legal proceedings. A patient's medical record must contain all the necessary documentation to support the services rendered and billed, as well as the medical necessity of those services.
What is included in a patient's medical record?
· In general, a Personal Health Record (PHR) is controlled by the individual, and can be shared with others, including caregivers, family members and providers. This is different from a provider's electronic health record, which is controlled by the provider just as paper medical records are today. Ideally, a Personal Health Record will have a ...
Is the patient’s PHR the official medical record of the patient?
· Personal health records (PHRs), in conjunction with EHRs, are new technological tools that have promoted patients' participation in their healthcare decisions, correction of medical record errors, and increased access to medical care. 2. For many years, patients have kept paper copies of their medical records, but with this new technology ...
What is legal health record?
The legal health record serves to identify what information constitutes the official business record of an organization for evidentiary purposes. The legal health record is a subset of the entire patient database. The elements that constitute an organization's legal health record vary depending on how the organization defines it.
Is there a one size fits all definition of legal health records?
There is no one-size-fits-all definition for the legal health record and designated record set. The healthcare organization must explicitly define both in a multidisciplinary team approach. Medical staff, for example, should provide guidance to ensure that patient care needs will be met for immediate, long-term, and research uses. †
What is a designated record set?
The HIPAA privacy rule defines the designated record set as a group of records maintained by or for a covered entity that may include patient medical and billing records; the enrollment, payment, claims, adjudication, and cases or medical management record systems maintained by or for a health plan; or information used in whole or in part to make care-related decisions.
What is the fifth step in a health record?
The fifth step is determining how to classify external records received by the organization. Some state laws address how to classify external records; however, in the absence of state law, the organization must determine if external records will be a part of the health record.
What is the privacy act of 1974?
The Privacy Act of 1974, like the HIPAA privacy rule, gives individuals the right to access and request amendments to their records.
Do states have health information?
Many states have laws or regulations that give individuals the right to their health information. Some state laws may define health information more broadly than the privacy rule. Some states may not limit access and amendment to PHI in a designated record set.
What are some examples of patient-identifiable data?
There are many types of patient-identifiable data elements that are pulled from the patient's healthcare record that are not included in the legal health record or designated record set definitions. Administrative data and derived data and documents are two examples of patient-identifiable data that are used in the healthcare organization.
What is legal health record?
AHIMA defines the legal health record as "generated at or for a healthcare organization as its business record and is the record that would be released upon request. It does not affect the discoverability of other information held by the organization. The custodian of the legal health record is the health information manager in collaboration with information technology personnel. HIM professionals oversee the operational functions related to collecting, protecting, and archiving the legal health record, while information technology staff manage the technical infrastructure of the electronic health record." 1
Is a health record hearsay?
Historically, health records were considered hearsay and inadmissible in legal proceedings. However, the Federal Rules of Evidence and the Uniform Rules of Evidence codified the business records exception to the hearsay rule, thereby allowing health records to be used at trial. 6
What is the purpose of authenticating a medical record?
The purpose of authentication is to show authorship and assign responsibility for an act, event, condition, opinion, or diagnosis. 3 Every entry in the health record should be authenticated and traceable to the author of the entry. The Rules of Evidence indicate that the author of the entry is the only one who has knowledge of the entry. The Federal Regulations/Interpretive Guidelines for Hospitals (482.24 (c ) (1) (i)) require that there be a method for determining that the author did, in fact, authenticate the entry. 4 This process should be defined in HIM written policies and procedures and substantiates the authentication of an entry in a legal process.
