HI 103

1. © 2017 American Health Information Management Association© 2017 American Health Information Management Association
Chapter 9: Legal Health Record:
Maintenance, Content,
Documentation, and Disposition
Fundamentals of Law for Health
Informatics and Information
Management, Third Edition

2. © 2017 American Health Information Management Association
Purposes of the Health Record
• Patient care: Documentation patient treatment and continuity
of care
• Proof of services for reimbursement
• Proof of quality and effectiveness of care (e.g., for
accreditation, certification, licensure)
• Support medical research
• Support education and training
• Support organization’s operational activities
• Facilitate managerial decision-making to improve quality of
patient care
• A legal document/evidence in legal actions
– Adage: “If it isn’t documented, it wasn’t done.”

3. © 2017 American Health Information Management Association
Legal Health Record (LHR)
• Business record that would be disclosed upon
valid request
• Content of LHR must be identified and managed
by inventorying all source systems contributing to
the record (e.g., paper and electronic documents,
databases, images)
• Organizations must determine what becomes part
of the LHR, analyzing inclusion of items such as
– E-mails
– Videos
– Metadata

4. © 2017 American Health Information Management Association
Designated Record Set vs. LHR
• Per HIPAA, a designated record set (DRS) is
“used in whole or in part…to make decisions
about individuals” and includes health
records and records involved in billing,
insurance enrollment and coverage
• A DRS encompasses more information than
what is usually considered part of the legal
health record

5. © 2017 American Health Information Management Association
LHR: Paper vs. Electronic
Health Records
• Six key differences:
– Large volume and ease of duplication
– Persistence: Electronic documents more likely to
continue to exist
– Metadata: Tracking data about data
– Automatic updates
– Obsolescence: With outdated programs or
equipment
– Searchable and dispersed in multiple locations;
more likely with electronic records

6. © 2017 American Health Information Management Association
LHR: Uniform Photographic
Copies of Business and Public
Records as Evidence Act (UPA)
• Both federal and state versions exist
• Supports the transition from paper to
electronic storage of information
• States that the reproduction of any record
that has been retained in the regular course
of business and kept by a process which
accurately reproduces the original in any
medium will be admissible as evidence

7. © 2017 American Health Information Management Association
LHR: Maintenance, Content,
Documentation and Disposition
• Federal Laws
– Medicare Conditions of Participation
• State laws
• Accreditation standards
– Joint Commission
– Other standard setting organizations
• Professional guidelines—AHIMA
• Facility policies—outlined in medical staff
bylaws

8. © 2017 American Health Information Management Association
LHR: Documentation Principles
• Language:
– Entries should be
• Specific
• Objective
• Factual, not speculative or opinion (or should be documented as such)
• Devoid of generalizations or vagueness (e.g., confused, anxious,
appears to be…)
– Response to care should be documented
– Deviations from standard treatment (and patient response) must
be documented completely
– Situations that result in incident reports should be documented
objectively
• Blame or failure should not be documented in the record

9. © 2017 American Health Information Management Association
LHR: Documentation Principles
(continued)
• Individuals who may document
– Documentation in the record shall be completed only by
those authorized per medical staff bylaws
– Providers are responsible to provide high-quality and
complete, authenticated documentation
• Gaps and omissions
– Detract from the chronology of care and increase
likelihood of liability
– Gaps: Spaces left between entries in the health record
– Gaps and omissions in time refer to lengths of time when
there is no documentation

10. © 2017 American Health Information Management Association
LHR: Documentation Principles
(continued)
• Orders:
– Written
– Verbal (in-person and telephone)
• Illegibility of orders is progressively being resolved through
CPOE
• Medical staff bylaws specify categories of personnel who may
accept orders
• All orders must be authenticated (verified) by the provider who
gave the order or who is responsible for the patient’s care
– Time requirements for authentication are governed by state law
• Concurrent review of orders ensures timely authentication

11. © 2017 American Health Information Management Association
LHR: Documentation Principles
(continued)
• Hostile patients
– Require particular attention to objective
documentation
• Staff disagreements
– Differing opinions must be documented in the
record if pertinent to care
– However, documentation should not highlight
disagreements
– Language must be objective and factual

12. © 2017 American Health Information Management Association
LHR: Documentation Principles
(continued)
• Injuries resulting from criminal activity
– Objective and factual documentation
– Documentation should include statements
made, identification and thorough description
of of injuries, and photos
• Liability for improper entries
– Heightened is documentation is missing,
incomplete, biased, critical, and based on
opinions rather than fact

13. © 2017 American Health Information Management Association
LHR: Legally Defensible Record
• Data governance: Associated with data
creation
– Emphasis on accuracy and integrity
• Information governance: Associated with
information after it has been created
– Emphasis on safeguarding and protection

14. © 2017 American Health Information Management Association
LHR: Legally Defensible Record
• Authentication and attestation
– Authenticity: Genuineness of a record; that it is
what it purports to be
– Authentication: Security process that verifies
one’s identity and authorizes system access
– Attestation: Applying a signature to
documentation, showing authorship
• Paper records: Handwritten signatures; initials; rubber
signature stamps (not favored)
• Electronic records: Digitized signature; button, PIN,
biometric identifier or token; digital signature (all
referred to as electronic signatures)

15. © 2017 American Health Information Management Association
LHR: Legally Defensible Record
(continued)
• Uniform Electronic Transactions Act (UETA):
electronic records and signatures legally
equivalent to paper records and handwritten
signatures
• Electronic Signatures in Global and National
Commerce Act (E-SIGN): Validates electronic
records and signatures, to be legally recognized
for interstate and foreign commerce

16. © 2017 American Health Information Management Association
LHR: Legally Defensible Record
(continued)
• Attestation issues:
– Countersignatures
– Multiple attestations
– Attestation on behalf of another
– Auto-attestation
– Batch signing
– Scribes

17. © 2017 American Health Information Management Association
LHR: Legally Defensible Record
(continued)
• Integrity of electronic record content
– Metadata: Provides background information
about actions that affect creation, revision,
and access to data
– Documentation templates: Increase efficiency
and structure, but create integrity issues

18. © 2017 American Health Information Management Association
LHR: Legally Defensible Record
(continued)
• Accuracy: Degree to which information in the
record reflects what actually happened
• Authorship and Cut, Copy, Paste (Cloning):
– Information may be placed on wrong encounter or
wrong patient
– Medical plagiarism: Using another’s documentation
without permission
– Risks of healthcare fraud when documentation from
another provider or another patient’s record is used

19. © 2017 American Health Information Management Association
LHR: Legally Defensible Record
(continued)
• Abbreviations: Must use only organization-
approved abbreviations
– Must not use Joint Commission prohibited
abbreviations
• Legibility

20. © 2017 American Health Information Management Association
LHR: Legally Defensible Record
(continued)
– Changes to the health record: Only per
organizational policy
• Revisions: Replacing inaccurate information with
accurate information after attestation
• Additions:
– Late entry: Entry missed or not written in timely manner
– Amendment: Information added to support or clarify (HIPAA
individual right)
– Addendum: New documentation added to original entry after
attestation

21. © 2017 American Health Information Management Association
LHR: Legally Defensible Record
(continued)
• Changes to the health record:
– Removal:
• Deletion: Permanent elimination of information
(limited, if permitted at all)
• Retraction: Information no longer available for
viewing but is available in the background
– Version management: How an organization
handles numerous iterations of a document
• If used for patient care, must be retained

22. © 2017 American Health Information Management Association
LHR: Legally Defensible Record
(continued)
• Timeliness and completeness:
– Timeliness: Promptness of documentation
– Completeness: Comprehensiveness of
documentation
– Mandated by accrediting and licensure bodies
– Important from evidentiary standpoint

23. © 2017 American Health Information Management Association
LHR: Legally Defensible Record
(continued)
• Printing
– Problems:
• Documents printed from EHR, with handwritten
documentation on printouts (which one is the LHR?)
• Duplicate copies lead to cumbersome records
• Multiple copies heighten risk of privacy breaches
• Printed version does not look like record viewed on computer
screen, raising questions re: whether the two records are the
same
– Strict printing policies are important
• Who has authority to print
• Tracking printing in an audit tail
• Format and version of documents that may be printed

24. © 2017 American Health Information Management Association
LHR: Legally Defensible Record
(continued)
• Personal health records (PHRs)
– Standalone PHRs
– Tethered PHRs
– Information provided by the patient
– Question re: whether the PHR should be
integrated into the LHR

25. © 2017 American Health Information Management Association
LHR: Identification, Retention
and Disposition
• Health Record Identification
– Master Patient Index (MPI) and Enterprise Master Patient Index
(EMPI)
• Patient matching
• Health Record Retention
– Storage and retrieval
– Factors affecting retention periods:
• Federal and state laws
• Statutes of limitations
• Accreditation standards
• AHIMA recommendations (best practice)
• Operational needs
– Record retention schedules (paper record retention vs. electronic
record retention)

26. © 2017 American Health Information Management Association
LHR: Identification, Retention
and Disposition
• Health Record Disposition
– Includes destruction or transfer to another medium or
custodian
– Must consider many of the same factors as those
considered for retention periods
– Destruction policy and procedure must consider:
• Schedule for uniform destruction
• Protection of information set for destruction (HIPAA)
• Maintaining records scheduled for destruction that must be
retained (eg, lawsuits, audits)
• Method of destruction (shredding, burning, degaussing, etc.)

27. © 2017 American Health Information Management Association
LHR: Identification, Retention,
and Disposition
• Health record disposition
– Transfer policy and procedure must consider:
• Moving from one medium to another (e.g., paper to
document management system)
• Moving records to another custodian
– Ownership change
– Departing providers
– Closure of organization
– Organization may be liable for failure to produce
health record (paper or electronic) that should be
available per policy and applicable laws