AHIMA PRACTICE BRIEF: DEFINITION
OF
THE HEALTH RECORD FOR LEGAL PURPOSES*
Methods for documentation of
confidential patient healthcare information are evolving from traditional hardcopy
medical records to systems that are increasingly computer- and network-based. While
this development offers many advantages for coordination of patient care and reimbursement
for services rendered, it also presents security and privacy challenges. Large quantities
of privileged information are now shared via virtual formats that are potentially
subject to unauthorized access. Accordingly, contents of these electronic medical
records and their integrity are of growing concern to regulatory agencies and healthcare
consumers alike.
Laws and regulations defining the
makeup of the patient medical record can differ from state to state. Medical record
content can also vary by clinical facility. However, a new practice brief published
October 2001 in the Journal of the American Health Information Management Association
(AHIMA) seeks to establish an authoritative and legal standard for information that
should be universally included in the healthcare record. With the introduction of
the virtual medical record and Health Insurance Portability and Accountability Act
(HIPAA) privacy guidelines, this issue has assumed special importance.
The AHIMA defines the Legal Health
Record (LHR) as “the documentation of the healthcare services provided to an individual
in any aspect of healthcare delivery by a healthcare provider organization.” A list
of documents routinely found in the LHR is outlined in this practice brief. Defense
attorneys and paralegals will find this inventory to be a valuable resource when
attempting to identify relevant plaintiff medical records during the discovery phase
of litigation.
It is important to understand the
information a patient's medical record will not typically include. The AHIMA indicates
that the LHR should exclude those documents that are not official business
records of a healthcare provider, as is the case with personal health records
(PHRs), which are materials controlled, managed, and populated by the patient. An
exception is the documentation released by the patient to the healthcare provider
for purposes of care planning and delivery. Records of serum glucose self-monitoring
are one example.
An adjunct component of the organization’s
legal business record is patient-identifiable source data. This information
is typically stored separately from the LHR and may include items such as physician
dictation audiotapes, digital patient photographs, diagnostic films, fetal monitoring
strips, videotapes of examinations and procedures, recordings of telemedicine consultations,
and similar items. The AHIMA notes that in the absence of reports containing summaries
or interpretations of patient-identifiable source data, the source data itself should
then be considered a part of the LHR and be retrievable upon request.
Administrative data, such
as birth and death certificates, incident and accident reports, clinical practice
guidelines, patient information reviewed for quality assurance analysis, requests
for release of information, and similar materials, are also not regularly maintained
in the patient’s LHR. Other information not considered part of the LHR is derived
data, which is material extracted from patient medical records for preparation
of various institutional statistical, accreditation, public health, research, and
other reports. As with administrative data, derived data records will not normally
be provided in response to an attorney’s subpoena requesting the patient's “medical
record.”
Once an attorney or paralegal acquires
a full appreciation of the documents characteristically found in the patient’s Legal
Health Record, he or she can more effectively retrieve this information from healthcare
providers and enhance planned defense strategy. To learn more about the LHR and
other patient data sources, consult the complete AHIMA practice brief available
online from the organization’s web site at http://www.ahima.org/journal/pb/01.10.2.html.
Reviewed by:
Elizabeth B. Juliano
James R. Fell
* American Health Information
Management Association. Practice Brief: Definition of the Health Record for Legal
Purposes. Journal of AHIMA, 2001;72(9):88A-H.
Return back to articles page.
![MY LM[I]SIGHT](../gifs/account_blue.gif)
