* There are two views on whether external records referenced for patient care are part of the statutory health record. One view is that they should be if they were relied upon to make care decisions. The other view is that while they are part of the established dataset and available for patient care and disclosure, they should not be because the organization is unable to confirm how the external datasets were originally created. Organizations should consult with their lawyers to assess the risks and benefits of both approaches. The challenge for HIM professionals in defining the statutory health record or overall record is to determine which data elements, electronically structured documents, images, audio files, and video files to include. The primary consideration when defining the statutory health record and the named record should always be the need for immediate and long-term care for patients. A HIM committee, composed primarily of members of the patient care team, can lead this process. Members of this committee should decide what information is clinically significant† “Lions, tigers and bears, oh my God!” This phrase from The Wizard of Oz often comes to mind when I talk about the distinction between a medical record, a specific record, and a legal medical record. The following matrix is a tool that allows organizations to identify and track the paper and electronic portions of the health record during EHR implementation and ongoing maintenance.
IM professionals can tailor this matrix to the needs of their organization and add specific elements that should be considered when implementing an EHR. It is up to each organization to determine what health information is considered part of its statutory health record. There is no uniform definition of legal health record and defined record. The health care organization must explicitly define both in a multidisciplinary team approach. For example, medical staff should provide guidance to ensure that patients` care needs are met for immediate, long-term and research purposes.† Some types of records belong to both the specified record and the statutory health record. Some belong only to the specified record. By categorizing record types, organizations can define policies for each recordset. Statutory health records EXCLUDE medical records that are NOT official business documents of a health care provider (even if copies of documentation of health services provided to an individual and shared with an individual by a health care provider organization are provided to and shared with the individual).
Therefore, records such as personal health records (PHRs), which are controlled, managed and completed by patients, would not be part of the statutory health record. Debbie joined Haugen Consulting Group with over 20 years of experience managing health information operations. Debbie has been involved in all aspects of the EOI, including reorganizing the department, streamlining workflow, implementing and retiring EHRs, managing document images, coding and improving clinical documentation, data integrity, and information sharing. For years, healthcare organizations have struggled to define their legal health records and align them with the record required by HIPAA`s privacy rule. Questions often arise about the differences between the two sentences, as both identify information that must be disclosed upon request. Questions to ask include whether the source system can print or download to a CD, how the requester accesses it, and whether it is in an understandable format. The legal health record elements and defined dataset must be reproducible in an accessible format. See Appendix B for a comparison of the statutory health record with the planned dataset. The legal business record generated by or for a health care organization. This file would be made available upon request.
There are many types of patient-identifiable data elements extracted from the patient`s medical record that are not included in the statutory health record or established record definitions. Administrative data and derived data and documents are two examples of patient identification data used in the healthcare organization. PSI is a broad and diverse set of information contained in the WASH that does not meet the definition of LMR or SDR. We called this OPSI, which is a subset of the EPDS and is defined as information that can relate to the patient`s current health status. Our OPSI AMC includes, but is not limited to: The following table provides examples of documents that are not included in the specified record. According to ahima.org, the following should be considered when defining the legal health record. The third step in determining the legal health record is to ensure that the components are properly stored. Storing EHR components in different systems can cause problems.
Information management professionals should identify and work with IT professionals and system owners to define retention policies and practices. Without adequate retention of the EHR, compiling the complete dataset for dissemination may not be possible. Medical images and photographs ARE clinically relevant and used for medical decision-making. The complication experienced by many institutions is the centralized storage and quality reproduction of images when publishing the legal medical record, especially on paper. If the images are kept in different systems and devices that HIM may not have immediate access to, it will be difficult to include and share them consistently in the LHR definition. When documents are published on paper, the quality of a reproduced image, especially with monochrome printers, is compromised and can be completely unreliable. If the documentation refers to what can be seen in the medical images and interpreters, these reports would be part of the RSL and could meet the requirements of many release applications. And while these considerations may lead some institutions to exclude medical images from their definition of RSL, that doesn`t mean they`re not useful and can be released upon specific request. The business record generated by or for a health care organization.
It is the document that is communicated upon receipt of an application. The legal health record is the officially declared record of health services provided to an individual by a provider. Organizations should follow the following common principles when defining their medical records and legislated record sets. Therefore, using our AMC model, this external information falls into the OPSI category. The best example in this category is unsolicited medical records from an external source. As an example of OPSI, it`s easy to see the vast amounts of patient data that can include years of medical history, notes, and test results, most of which are not relevant to the patient`s current care. Our CGA policy requires the receiving provider to “determine” which external documents, if any, should be included in the DRS to support the clinical care provided by our CMA. Patient-identifiable source data is data from which interpretations, summaries, notes, etc. are derived.
Source data should be given the same level of confidentiality as the legal medical record. This data is increasingly recorded multimedia. For example, the video recording of the meeting would not represent the legal health record, but would be considered source data. In the absence of documentation (e.g. Interpretations, summaries, etc.) The source data should be considered part of the legal health record. Now that you know the basics, let`s see what a medical record should contain.
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