Guidelines to Manage Health Information

Developing a legal health record policy

CHICAGO, October 2, 2007 — Health records’ main purpose is to document the care and services provided to patients, according to an article in the October issue of the Journal of AHIMA. However, health records must be managed in a way that complies with applicable regulations, accreditation, professional practice and legal standards. These standards may vary based on care settings, legal jurisdictions and locations.

Because of these variances, an organization is responsible for identifying the content required for its legal health record, including the standards for maintaining the integrity of that content. This rule applies to all methods used to create and store health records—paper, electronic or hybrid.

Therefore, it is imperative that organizations consult with legal counsel to develop their legal health record policy. The policy identifies the health record of a company for business and legal purposes while ensuring health record integrity is maintained, allowing it to support business and legal needs.

The Journal article also provides considerations and questions that organizations transitioning to electronic health records should address, such as maintaining the integrity of the legal health record, health information exchange, downtime documentation, authentication, metadata and document completion (lockdown).

About AHIMA

AHIMA is the leading professional Association representing more than 51,000 specially educated and certified health information management professionals working throughout the healthcare industry.  HIM professionals serve healthcare and the public by managing, analyzing, and utilizing data vital for health system management.