AHIMA RELEASES GUIDELINES FOR DEFINING THE LEGAL HEALTH RECORD
No one size fits all definition exists, only common principles

CHICAGO, September 1—Regardless of a health record’s format—paper, hybrid or fully electronic—healthcare organizations must ensure that it meets the requirements of a legal health record, according to the American Health Information Management Association (AHIMA). In the September issue of the Journal of AHIMA, the Association releases its guidelines for defining the legal health record.

“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,” states 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 that developed the guidelines to assist organizations in defining their health record for legal applications.

According to the work group, each organization must define the content of the legal health record to best fit its system capabilities and legal environment. Considerations for the content of the legal health record 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 the requirements of third-party payers.

“Unfortunately there is no one-size fits all definition as the laws and regulations governing the content vary by practice setting and state. However, there are common principles that can be followed in creating a definition,” adds Julie McQueary, RHIA, application analyst for Capgemini America and co-chair of the e-HIM® workgroup.

For a copy of the workgroup’s complete report, “Guidelines for Defining the Legal Health Record for Disclosure Purposes,” visit AHIMA’s Web site at http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_027921.hcsp.

The e-HIM® work group consisted of AHIMA members from various provider settings, law practices, information technology vendors, and information systems consultants. AHIMA provides its industry-leading e-HIM™ education and advocacy programs to support the effective use of information technology to manage patient information and healthcare data. The workgroup was funded by a grant to the Foundation of Research and Education (FORE) from Precyse Solutions.

FORE provides financial and intellectual resources to sustain and recognize continuous innovation and advances in HIM for the betterment of the profession, healthcare, and the public. For more information about FORE, go to www.ahima.org/fore.

AHIMA is the premier association of health information management (HIM) professionals. AHIMA’s 53,000 members are dedicated to the effective management of personal health information needed to deliver quality healthcare to the public. Founded in 1928 to improve the quality of medical records, AHIMA is committed to advancing the HIM profession in an increasingly electronic and global environment through leadership in advocacy, education, certification, and lifelong learning. For information about the Association, go to www.ahima.org.