Developing a Legal Health Record Policy: Appendix A

The tables below provide examples of a matrix tool that can help organizations identify and track the paper and electronic portions of the legal health record during and up to the full implementation of a paperless environment. Items for special consideration as to whether to include on the matrix may include those listed below. It is up to each individual organization to determine what health information is considered a part of their legal health record.

• Alerts, reminders, pop-ups
• Continuing Care Records (unless used in the provision of patient care)
• Administrative data/documents: patient-identifiable data used for administrative, regulatory, healthcare operations, and payment (financial) purposes
• Derived data/documents: information aggregated or summarized from patient records so that there are no means to identify patients.
• Data/documents: documentation of patient care that took place in the ordinary course of business by all healthcare providers.
• Data from source systems: written results of tests. Data from which interpretations, summaries, notes, flowcharts, etc., are derived.
• New technologies: audio files of dictation or patient telephone calls, handwritten nursing shift-to-shift reports, telephone consultation audio files, videos of office visits, and videos of procedures or telemedicine consultation.
• Personal health records (PHRs): copies of PHRs that are created, owned, and managed by the patient and are provided to a healthcare organization (s) might be considered part of the legal health record if so defined by the organization.
• Research records: organizational policy should differentiate whether research records are part of the legal health record and how these records will be kept.
• Discrete structured data. Laboratory orders/refills, orders/medication orders/MARs, online charting and documentation and any detailed charges.
• Diagnostic image data: CT, MRI, ultrasound, nuclear medicine, etc.
• Signal tracing data: EKG, EEG, fetal monitoring signal tracings, etc.
• Audio data: heart sounds, voice dictations, annotations, etc.
• Video data: ultrasound, cardiac catheterization examinations, etc.
• Text data: radiology reports, transcribed reports, UBS, itemized bills, etc.
• Original analog document – document image data: signed patient consent forms, handwritten notes, drawings, etc.

Maintaining the Legal EHR: Verification Legend Document Principles

O* Allowed and monitored—based on reported and randomized audits to determine adherence to policies and procedures for accurate, timely, and complete documentation principles.
X* Prohibited and monitored—based on reported and randomized audits to determine prohibited use of copy and past, pull forward, etc.