Health records of any kind must match the requirements of a legal health record, so declares the American Health Information Management Association (AHIMA) in this month's issue of the Journal of AHIMA.
In the journal, the organization has defined guidelines for health records which healthcare organizations must meet.
"The definition of the legal health record must be continuously reassessed in light of new technologies, users, and uses. With the advent of various electronic media, the internet, and the consumer's enhanced role in compiling their health information, the definition of the legal health record has become more complex," said Cheryl Servais, MPH, RHIA, corporate vice president of compliance and privacy officer for Precyse Solutions and co-chair of the AHIMA electronic health information management (e-HIM) workgroup.
Organizations are being asked by the workgroup to define the content of the legal health record in whatever way best fits each unique system and legal environment.
Considerations should include:
- Ease of access to different components of patient care information;
- Guidance from the medical staff and the organization's legal counsel;
- Community standards of care, federal regulations, state law and regulations;
- Standards of accrediting agencies, and
- Requirements of third-party payers.
For a copy of the workgroup's complete report Guidelines for Defining the Legal Health Record for Disclosure Purposes visit: http://library.ahima.org/xpedio/groups/public/documents/ahima/pub_bok1_027921.html