Summarizes the latest changes in what currently constitutes a legal health record. The book explains the legal process at it applies to electronic health records (EHRs) and describes the foundation for a legal record. Discusses EHRs versus legal EHRs and how maintaining the legal EHR is especially useful for evaluating in-house policies. Compiled from the latest expert knowledge of industry professionals, the information here has been thoughtfully summarized and explained so you can move forward with confidence. Included in the appendix material is the compendium of existing literature covering the emerging issues for HIM professionals and health law attorneys. Gain a snapshot of the “state of the industry” as it evolves!
Get the information you need to move forward with the legal EHR responsibly.
The Legal Health Record informs you in several key areas, including:
-
The EHR as a business record
-
How rules of evidence apply to health records
-
The new Electronic Discovery rule and how it applies to the EHR
-
Recommended content for the legal EHR
-
Possible future directions for the legal EHR
-
Communication on the importance of the legal EHR as interoperability, RHIOs, and PHRs gain public awareness
-
Discussion of national issues relating to privacy, and patient rights and responsibilities
-
Superior content focus on “the six As” of legal EHRs: accuracy, authorship, authentication, audit trails, amendments, and alternatives
Cheryl E. Servais, MPH, RHIA
Neil S. Olderman, JD
Kelly A. Trahan, JDChapter 1. Introduction to the legal Health Record
Chapter 2. Defining the Components of the Legal Health Record
Chapter 3. Electronic versus Legal Health Records
Chapter 4. Maintaining the legal Health Record
Chapter 5. Electronic Health Records and the Legal Process
Chapter 6. Summary and Conclusions
Appendix of Resources:
Complete Medical Record in Hybrid HER Environment: Task Force Report
Core Data Sets for the Physician Practice Electronic Health Record
Correcting and Amending Entries in a Computerized Patient Record
Defining the Designated Record Set
Definition of the Health Record for Legal Purposes
Disaster Planning for Health Information
Document Imaging as a Bridge to the HER
Documentation Requirements for Acute Care Inpatient Record
E-Discovery and HIM: How Amendments to the Federal Rules of Civil Procedures Will Affect HIM Professionals
E-Discovery: preparing for the Coming Rise in Electronic Discovery Requests
The EHR’s Impact on Health Information Management (HIM) Functions
Electronic Documentation Management as a Component of the Electronic Health Record
Foundational Concepts of the legal HER
Getting Off to a Good Start: Tips from the Launch of Two HIM Systems
Guidelines for Defining the Legal Health Record for Disclosure Purposes (Update)
Guidelines for Electronic Health Record Documentation to Prevent Fraud
Helping Consumers Select PHRs: Questions and Considerations for Navigating an Emerging Market.
HIPAA on the Job: A Primer on Encryption
In Emerging Data Networks, a Role for HIM: Regional Data Exchange Presents New Questions for Fundamental HIM Issues
Implementing Electronic Signatures
Keep It Clean: Optimizing EHRs Starts with Ensuring Data Quality
The Legal Process and Electronic Health Records
Maintaining a Legally Sound Health Record—Paper and Electronic
The New Electronic Discovery Civil Rule
A Quick Scan of Bar Coding
Recommended Regulations and Standards for Specific Healthcare Settings
Record Disclosure and the HER: Defining and Managing the Subset of Data Disclosed upon Request
Redisclosure of Patient Health Information
Retention of Health Information (Update)
The Strategic Importance of Electronic Health Records Management: Checklist for Transition to the HER
Understanding the HER System Functional Model Standard
Unwrapping Data Standards
Using Test Vignettes to Assess HER Capabilities