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The Health Record: Definitions And Online Resources For The Retrieval And Analysis Of Medical Information

By: Elizabeth B. Juliano
Carey J. Marousek
Dean F. Slejko
Copyright © 2006 Litigation Management, Inc. All Rights Reserved.

Definition of the Health Record

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, an updated practice brief published in September 2005 by the American Health Information Management Association (AHIMA) provides guidelines for defining the legal health record (LHR) in light of new technologies, users, and uses.

AHIMA, founded in 1928 to improve the quality of medical records, defines the legal health record 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 updated 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.

The update also provides guidance on a number of issues to ensure information is accessible for its ultimate purposes, regardless of the technologies employed or users involved. Topics include:

  • Meeting HIPAA privacy standards
  • How to handle information created as paper documents, in electronic media, and in hybrid (part paper, part electronic) environments
  • How to handle alerts, reminders, pop-ups, and continuing care records
  • What data and documents to include in the record, as well as what to exclude
  • How to handle source-system data (from which interpretations, summaries and notes are derived)
  • Continuation or recreation of patient care documentation when electronic systems are unavailable
  • Emerging issues including audio and video records
  • Consideration of personal health records

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, consult the updated AHIMA practice brief available online as follows:

http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_027921.hcsp?dDocName=bok1_027921

Online Resources That Assist In Retrieval Of Medical Information

Identifying and locating health care providers can be a time-consuming process. The following resources may help shorten the time required to request and obtain relevant medical records.

Online Locators for Physicians & Other Health Care Professionals

    • National Library of Medicine/National Institute of Health http://www.nlm.nih.gov/medlineplus/directories.html (Medline Plus link to directories of health professionals, services and facilities).

      • Note the tab linking to Other Resources that provides links to additional information and other databases beyond Medline Plus. This is a primary reference tool that includes many of the specific links below.

    • American Medical Association      www.AMA-assn.org

      • Searches available for AMA physician members and non-members. The AMA provides additional links to condition- and illness- related Web resources, medical indexes and government health sites.

    • American Board of Medical Specialties     www.ABMS.org

      • The American Board of Medical Specialties (ABMS) is the umbrella organization for the 24 approved medical specialty boards in the United States. The ABMS maintains a list of all board certified diplomates. Search engines are available by name or area of certification and city and state. This site requires registration.

    • Physician search websites

    • American Board of Internal Medicine     www.ABIM.org

      • The American Board of Internal Medicine is the only recognized board in the specialty of internal medicine and is one of the 24 certifying boards of the American Board of Medical Specialties. Search engines are available for verification of certification status.

    • American Osteopathic Association     http://www.osteopathic.org/

      • Search engines available for finding a D.O. and for finding a D.O. by state.

    • American Dental Association     www.ADA.org

      • Searches available to access a directory to find a dentist.

Online Locators for Hospitals

    • Association of Community Cancer Centers     www.accc-cancer.org

      • This website has search engines available to locate cancer centers by state.

    • American Hospital Directory     www.ahd.com

      • The American Hospital Directory provides on-line data for over 6,000 hospitals. Search engine available to identify hospitals by name and location.

    • Hospital Directories     www.hospitalsoup.com

      • Worldwide directory and hospital information services website. Search engine available to locate all hospitals within a geographic location by state, or by city and state.

Online Resources To Help Comprehend The Medical Record

The following resources can aid in deciphering, summarizing and analyzing plaintiff medical records.

Online Medical Dictionaries

    • Stedman's Online Medical Dictionary     www.stedmans.com

      • Hardcopy of this medical dictionary has always been a "must have" for any medical legal reference collection. The online version is comprehensive and user friendly. No access fee or registration is required at the present time. Provides useful links to words that are similar or related to the search term.

    • Taber's Online     www.tabers.com

      • The hardcopy version of Taber's is another standard among medical dictionaries. The online version requires registration, with a one-year subscription fee of $29.95. Special rates apply for multi-users.

    • Merriam Webster Medical Dictionary     http://www.intelihealth.com/IH/ihtIH/WSIHW000/9276/9276.html

      • This reference can provide an additional resource for defining medical terms. No registration or subscription is required through the above address.

    • Multilingual Glossary of Technical and Popular Medical Terms     http://allserv.rug.ac.be/~rvdstich/eugloss/welcome.html

      • Provides a glossary of medical terminology in Danish, Dutch, English, French, German, Italian, Portuguese, and Spanish. Functions allow users to locate terms through a quick search engine or via browsing. No registration or access fee required.

Medical Encyclopedias

    • A.D.A.M. Health Illustrated Encyclopedia     http://www.nlm.nih.gov/medlineplus/encyclopedia.html

      • Produced by the Atlanta-based A.D.A.M., Inc. The encyclopedia holds the seal of approval from the American Accreditation Healthcare Commission for quality Internet-based healthcare information. Claims to offer over 4,000 publications about diseases, symptoms, surgeries, etc. No registration or subscription required.

    • Merck Manual of Diagnosis and Therapy     http://www.merck.com/pubs/mmanual

      • A very highly respected reference that should be one of the first sources consulted when attempting to understand a new disease or medical condition. Excellent overview of the pathology, diagnostics, treatment, etc. for a given disorder. Users can navigate with a very efficient search engine or browse subject areas chapter by chapter. No registration or subscription fee required.

    • Merck Manual of Geriatrics     http://www.merck.com/pubs/mm_geriatrics

      • Provides information types similar to the Manual of Diagnosis and Therapy but is specifically geared to the elderly patient. Useful chapters on pressure ulcers, falls and fractures, malnutrition, and other topics relevant to defending nursing homes and health care providers employed by these facilities.

    • McGraw-Hill's AccessMedicine     http://www.accessmedicine.com/public/learnmore_clinical.aspx

      • Subscription resource that provides answers to clinical questions from the most trusted sources including Harrison's Online, Adams & Victor's Principles of Neurology and others. Subscriptions are available for each resource, or all can be accessed for an annual fee of $595.

    • Virtual Hospital     http://www.vh.org

      • On January 1, 2006, Virtual Hospital / Virtual Children's Hospital ceased operations after 13 years of service due to a lack of funding. However, much of Virtual Hospital / Virtual Children's Hospital content remains available online. This site contains a variety of links to informative materials. No registration or fee required.

Online Anatomical Resources

    • Visible Human Project     http://www.madsci.org/~lynn/VH/

      • The Visible Human Project was developed as part of the National Library of Medicine's 1986 Long Range Plan. It contains over 18,000 high-resolution, digitized sections of male and female cadavers in MRI, CT, and anatomical modes. Site visitors can access, search, and view these sections at no cost.

Online Pharmaceutical References

    • Physicians' Desk Reference     http://www.pdrhealth.com/

      • This free online resource provides drug information based on the FDA-approved information contained in the hardcopy version of the Physicians' Desk Reference, as well as clinical trial information.

    • Thomson Micromedex     http://www.micromedex.com/products/uspdi/

      • Originally created and edited by the United States Pharmacopeia until January 1, 2004 and now entirely edited and maintained by Thomson Healthcare, Inc., the three-volume series USP DI Drug References (hardcopy) is a respected source of pharmaceutical information This set consists of the titles, Drug Information for the Health Care Professional, Advice for the Patient, and Approved Drug Products and Legal Requirements.

Online Medical Literature

    • PubMed     http://www.ncbi.nlm.nih.gov/PubMed

      • Provided as a no-cost service of the National Library of Medicine. User can search some 11 million citations dating back to the 1950's. Hyperlinks from a given citation allow users to review an abstract of the article, if available. Other links connect to sites where full text articles may be purchased.

Expert Answers

    • MayoClinic.com     http://www.mayoclinic.com/findinformation/answers/index.cfm?

      • Visitors can search this site by keyword to determine if their particular question has been answered in the past. Due to the large volume of questions the service receives each week, only those inquiries determined to have educational value and interest to the general public will be selected for a response.

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