According to ahima.org, the following should be considered when defining the legal health record. You are trying to access a resource that is only available to AHIMA members. Sign up today to get full access to everything in the BoK, enjoy all the benefits of AHIMA membership, and be part of a network of over 103,000 health information management professionals. Recordings can be in different types of media, such as diagnostic images, voice files, videos, and emails. The components of a statutory health record may vary depending on how each health care organization defines it. Typically, it is the documentation of various medical services provided to a patient in any type of healthcare organization. The legal health record is important in this regard: Before the advent of the electronic health record, the legal health record was simply the content of a paper medical record. However, as more healthcare institutions adopt electronic health records and medical applications are increasingly used for patient monitoring and tracking data on various electronic forms, defining and creating a legal health record becomes increasingly complex. Now that EHRs are being used to review medical claims, healthcare providers must ensure that their EHR is a legal record and meets all legal, regulatory and professional requirements for clinical and commercial purposes.

It must be designed and used appropriately to ensure compliance with federal and state regulations, as well as institutional requirements and any additional certification standards that apply to each organization. The legal health record includes the documentation of a patient`s health information created by a health care organization. This important record is used in the health care organization as a business record and made available when requested by a patient or legal services. The LHR, or legal health record, is required for peer and peer reviews, as well as for the review of medical claims. Whether on paper or in electronic form, medical records must be kept in a legally sound manner, otherwise they can be challenged in court as invalid. The statutory health record is typically used to respond to a formal request for a medical record for legal purposes. This exercise mission has been discontinued. It is provided for historical purposes only. With respect to the disclosure of medical information, the following steps may be considered. Save my name, email address, and website in this browser for the next time I comment.