Resolution on the Legal Health Record

Submitted by AHIMA's Electronic Health Record Practice Council

Preamble

  1. Whereas, it is acknowledged that the health care industry is in transition to electronic health records and most health care organizations have health records that are in a hybrid state,
  2. Whereas, for evidentiary and business purposes it is required that healthcare providers maintain a legal health record documenting care and services provided to an individual regardless of the media used to record and store the information;
  3. Whereas, many electronic health record systems have limitations that may prevent their use as the legal health record;
  4. Whereas, simultaneous maintenance and retention of mixed media-based health records (e.g., paper/analog AND electronic/digital-based versions of the legal health record) increases the risk of producing inaccurate, incomplete, and/or conflicting information that could impact patient safety, the cost of maintaining health records, and healthcare costs in general;

Therefore, let it be

Resolved, that regardless of the media used to create and store health records, AHIMA advocates that organizations define one set of health information that meets the legal and business needs of the organization and complies with state and federal laws and regulations.

Resolved, that AHIMA advocates that, of the information that comprises the legal health record, organizations should document which exists in electronic media and which exists on paper and continuously update this documentation during the transition to electronic health records.

Resolved, that AHIMA advocates that organizations implementing electronic health records take steps to ensure that the functionality of their EHR system supports the legal health record, and develop a long term strategy for moving the legal health record to digital media and minimizing the risks associated with records in a hybrid state.

Approved by the 2006 House of Delegates, October 8, 2006, Denver, Colorado