Patient Records as Legal Documents

The importance of maintaining complete and accurate patient records cannot be underestimated. They serve not only as a basis for planning patient care but also as the legal record documenting the care that was provided to patients. The data captured in a patient record become a permanent record of that patient’s diagnoses, treatments, response to treatments, and case management. Patient records provide much of the source data for health care information that is created, maintained, and managed within and across health care organizations.

When the patient record was a file folder full of paper housed in the health information management department of the hospital, identifying the legal health record (LHR) was fairly straightforward. Records kept in the usual course of business (in this case, providing care to patients) represent an exception to the hearsay rule, are generally admissible in a court, and there­ fore can be subpoenaed—they are legal documentation of the care provided to the patients. With the implementation of comprehensive EHR systems the definition of an LHR remains the same, but the identification of the boundaries for it may be harder to determine. In 2013, the ONC’s National Learning Consortium published the Legal Health Record Policy Template to guide health care organizations and providers in defining which records and record sets constitute their legal health record for administrative, business, or evidentiary purposes. The media on which the records are maintained does not determine the legal status; rather, it is the purpose for which the record was created and is maintained.

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