Healthcare organizations can take the following basic steps to eliminate confusion about the legal health record and the intended record, as well as the disclosure of information from both: The huge amount of patient data in the electronic age has raised new questions about cost, meaningful access, long-term storage and accountability of patient information. Legal teams are grappling with the very real challenge of e-discovery. What PSRs should be retained for patient care and legal requirements and what system data is not required? The challenge for any organization is to clearly define in policies and procedures the organizational objectives related to the maintenance, storage and destruction of OPSI. Individuals do not have the right to access PSRs about them that are not part of a particular data set because that information is not used to make decisions about individuals. This may include specific quality assessment or improvement records, patient safety activity records, or business planning, development, and management records used for business decisions in general, rather than making decisions about individuals. For example, peer review files, practitioner or supplier performance reviews, quality control records used to improve client service, and formula development records may be generated from and contain an individual`s PSRs, but may not be included in the designated records of the seized company to which the individual has access. However, the underlying PSRs from the individual`s medical or payment records used to generate this information remain a part of the established record and are subject to the individual`s access. For example, an individual would not have the right to access internal memos related to the development of a formula; However, an individual has the right to access information about prescription drugs prescribed to him or her and claims records related to the payment of those drugs, even if that information was used in the development of the formula or helped to inform the individual. Purpose: The purpose of this policy is to establish guidelines for the definition and content of the record designated by [the organization] established in accordance with the Health Insurance Portability and Insurance Act (HIPAA) of 1996.
The definition of the elements of the medical record provided for by law and the designated file at the organizational level is clearly only the tip of the iceberg. The introduction of EHRs, which are considered the panacea for health information management, has resulted in additional levels of complexity. The introduction of electronic technology has allowed for the collection of large amounts of data for the patient record, but what remains a challenge is the ability to separate data elements based on policy definitions. As work continues to standardize key policies, we hope that technology can once again prove to be an essential addition to this complex equation. This is only the first part of the equation. The second part discusses the nuances of an electronic health record (EHR) versus an electronic medical record (EMR). Whatever term is used, something that comes up again and again in these presentations is a discussion about what information should be included in a patient`s medical record. Not so long ago, the definition of “medical records” was simple. It was the flipchart – volume by volume – that captured serial and conscientiously recorded events of a person`s health care in a hospital or doctor`s office. Entries were usually handwritten, dated and timed and signed (i.e.
authenticated) in ink and ink with title. Errors can be easily identified by an authenticated strikethrough. Similarly, the paper record was synonymous with a legal medical record (MRL). In other words, a patient`s paper record was, by definition, that patient`s MRL, even if critical data was omitted or irrelevant data was included. The legal health record is a legal business record formally defined for a healthcare organization. It includes documentation of health services provided to a person in any aspect of health care by a health organization.7,8 The health record is individually identifiable data in each medium that is collected and used directly to document health care or health status. The term also includes records of care in all health-related environments used by healthcare professionals to provide patient care services, review patient data, or document observations, actions, or instructions.9 The following matrix is a tool that companies use to identify the paper and electronic portions of the health record during implementation and ongoing maintenance of an EHR. and can follow.
HIM experts 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 legal health record and designated health record. The legal health record is the documentation of the health services provided to a person during any aspect of health care in any type of health organization. The definition of an organization`s legal health record should explicitly specify the sources, medium, and location of the individually identifiable data it contains (i.e., data collected and used directly to document health care or health status).† Documentation that includes the legal health record may be physically present in separate and multiple paper or electronic systems.