The Legal Health Record Companion: A case study approach

Practical advice and policy guidance to manage patient records for legal scrutiny

By most definitions, a health record is the set of documents used to provide optimum patient care and document the patient's progress across the continuum of care, generate a bill for appropriate reimbursement, and conduct audits and research.

Whether on paper, in a hybrid format, or completely electronic, the medical record is the industry Bible—the source from which all other records and documents are generated.

But medical records also serve as legal documents. At any time, a court may require a record as part of a legal proceeding, and you must be ready to provide it.

The Legal Health Record Companion: A case study approach is a hands-on resource tool that shows you how to define and develop health records that meet legal requirements. You'll learn how to use the health record appropriately and efficiently—from the legal point of view—as well as from the more familiar patient safety and common-sense perspective.

Developed from field experience

Authors Deborah Adair and Karen Griffin use actual case scenarios from Massachusetts General Hospital and Brigham & Women's Hospital in Boston to demonstrate how to put responsibility into best practice when developing sound and reliable legal health records.

You will learn how to

• document a true “reflection” or evidence of a patient’s true status
• create a legal health record definition that works for your facility
• protect the legal health record
• maintain the legal health record in a manner that ensures that the most accurate, well-organized, and accessible health information is available for the care and treatment of the patient
• employ best-practice operational standards

The authors also include sample policies your can customize for your organization, a pertinent question and answer section, and a glossary of frequently used terms.

What makes it a "legal" record?

It's not easy to define what comprises a legal health record. Every organization has its own procedures for which documents are added to its records. Forms and policies differ, even within the organization.

Professional organizations suggest record-keeping practices for clinical staff. Regulatory agencies add another level of record criteria. The HIPAA privacy and security rules place mandates on what defines a record.

Ultimately it is your organization’s responsibility to define its legal health record. That definition will change and you will continue to massage the definition as long as you have to—especially as you convert to electronic health records—to maintain the integrity of information you keep.

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