chapter 12: legal health record

Patient Record Documentation

Accuracy Patient-requested Amendments Corrections Deletions Copy and Paste Forward Late Entries Resequencing and Reassignment Templates, Boilerplates, Canned Text, and Structured Input

Uniform Rules for e-Discovery

Amendments to the FRCP specifically designed for electronically store information Apply to federal courts, but can be followed as guidance

LHR Definition Project Steps 2

Assess and Catalog EHR Systems for Their LHR Attributes Determine the Need for New and Revised Related Policies and Procedures Determine the LHR Maintenance Plan Conduct Education and Training for Appropriate Workforce Members

EHR System Functionality Relevant to the LHR

Audit Logs Authorship and Authentication of Entries and Electronic Signatures Business Continuity Business Rules Data, Document Management, and Nonrepudiation Retention, Data Permanence, and Migration Plans Interfaces Legal Hold Metadata Electronic Health Record Output Rendition Snapshots and Screen Views Privacy Attributes Version Controls

LHR Stakeholders

C-suite and practice managers HIM professionals Information technology staff Record custodians Privacy, compliance, and security officers Clinicians Legal counsel

Purpose of LHR Definition

Clarifies the roles of all records and their uses Sets foundational policy for record management operations Must be continually reviewed and updated as their constituent record components evolve

Legal Health Records

Describes the data, documents, reports, and information that comprise the formal business record(s) of any healthcare organization that are to be utilized during legal proceedings No standard terminology Recommend using legal health record defined for disclosure Dynamic process

LHR Definition Project Steps

Determine the LHR Stakeholder Team Determine Strategy and Plan; Get Executive Sponsorship and Empowerment Gather LHR-related Knowledge Develop a Master Source System Matrix Create a Document Matrix of LHR Components

LHR Defined for Disclosure

Determine what business records or components of records will be released upon legal request Use a spreadsheet or other tool to keep track of source systems and documents HIPAA Designated Record Set is a good starting point for the LHR

LHR Policy Imperative

Determines what data and information can or should be released pursuant to a request from a third party No policy leaves the organization at risk related to request for data and information that the organization is not prepare to release

Litigation Response Policies and Procedures

Failure to define these can increase liability and financial risk Starts with documentation of the steps and personnel already performing these tasks Customize practices to fit your specific requirements

Federal Rules of Evidence

Govern what and how electronic records may be used in a trial Roles of record custodianship for purposes of evidence in a trial Electronic records have many more requirements than paper records

e-Discovery Overview

LHR needs to be defined Disclosure—output and release upon request of appropriate health record documents E-discovery—process of discovering the relevant parts of a patient's record that may be used for litigation

LHR Governance

Laws—passed by legislatures Rules and Regulations—interpretations of laws Judicial Decisions—courts interpreting the laws Precedence—Previous decisions

Litigation Response Policy

The processes invoked if the potential for lawsuits or litigation is detected Maximize defensive posture Responses to subpoenas and court orders Protecting against spoliation (malicious alteration, concealment, or destruction of evidence)

Legal Processes

e-discovery—processes related to electronically maintained information Federal Rules of Civil Procedure (FRCP) Govern the procedures for civil trials Often also used to guide state court civil procedures State laws vary for subpoenas, court orders, discovery, and similar processes