Amanda Foster and Michelle Wisniewski

HIA322
Maryann OBrien
HEALTH RECORD PREPARATION
Your HIM department is served with a subpoena and the court or legal counsel is
requesting the medical record of a particular patient; what do you do next? Understanding
how to correctly identify the requested patient, the proper search and retrieval process as
well as the actual production of the records is necessary in order to produce a valid LHR
for court. AHIMAs Production and Disclosure of Health Information and Records for
E-Discovery outlines this daunting task and makes it much more manageable.
The first step in prepping a health record for court is to accurately identify the
patient that is being requested. This can be done using the master patient index (MPI),
any demographic information or identifiers, and medical record numbers. If there are any
aliases or multiple records used to find relevant information they must be noted in the
process. The HIM department would then notify the Litigation Response Team of the
subpoena and determine if a legal hold is in place. If no legal hold exists, the HIM
department would determine if one is necessary. The Litigation Response Team would
review the subpoena to determine if all elements are contained, the parties and purpose
are clearly identified, and the scope of information requested is clear. They would also
validate the service of the subpoena, validating if the organization is under legal
obligation to comply and verify that the seal and clerk of court signature are present and
valid. The Litigation Response Team would also review the jurisdiction of court and
venue before providing further direction to the HIM department. Once everything is
verified, the Litigation Response Team would then direct the HIM department as to what

specific information to produce, inform them of the agreed upon file formats, if there is
any objection to be filed, the timeframe to produce and disclose all information and if
there will be on-site testing or sampling that will be conducted by the requesting party. In
the even that all records are requested the HIM department should work with the judge or
the plaintiffs attorney to clarify the type of information being requested.
The search and retrieval process is the next step in preparing a medical record for
court. The Litigation Response Team should identify all potential sources of information
that may hold any relevant information such as but not limited to; the LHR/EHR system
(all information systems) the local area server for the office, any personal or shared
folders on the server, the sever for the organization, PDAs and laptops, all e-mail and
any removable storage media. Meanwhile, the HIM department and Data Owners should
establish parameters for patient identifiers and key words and will begin the search
process under the guidance of the Litigation Response Team. All systems that are
searched, all methodologies, terminologies and search results must be recorded. IT can
assist both the HIM department and Data Owners with the search and retrieval process.
The organizations legal services will review the content of the data and data sets,
determine the relevancy, identify any information that is privileged and create a final list
of relevant data and data sets and search methodology with the assistance from HIM and
Data Owners.
The production of the records is the third step in arranging a record for court. The
HIM department will work with Data Owners and IT to determine the format for which
the information will be disclosed; either paper form, PDF, screen shot etc. Once the
format is determined, they will produce the information in the agreed format. Any non-

relevant, privileged or confidential information is withheld from the production. All costs
for the search, retrieval and disclosure will be calculated using established formulas.
There will be a final review of the information by the organizations legal services before
disclosing anything to the requesting party.
In this process there may be testing and sampling requested on behalf of the court
or legal counsel, and this matter should be discussed during a pretrial conference. In the
pretrial discussion, both parties must agree upon external party testing, as well as the
search and retrieval methodologies. In the event that the methodology must be recreated
to determine if the sample was statistically valid, the HIM department and Data Owners
should have retained information of all of their searches. During the testing and sampling
the Litigation Response Team and the HIM department must monitor the process for the
outside party.
If there is a request to review the electronic data on behalf of a third party or
attorney, the Litigation Response Team must determine procedures for allowing the
review which may include where the review should take place, system controls and
charges. The HIM department and Data Owners must verify the outside party and
validate if they are allowed access to the record and systems. This can be reviewed by
supported documentation such as signed consent forms or credentials. If an authorization
is signed by the patient or legal representative then access will be granted to the legal
medical record or information that is outlined in the authorization.
When responding to interrogatories, depositions and court procedures, the legal
services will manage the process for compensation of the interrogatories and coordinate
processes related to a deposition and testify in court. The HIM department may supply

information for an interrogatory or testify the authenticity of the medical records. In the
event a paper copy of the EHR is produced the HIM Director may have to certify the
LHR produced; in that they will give information regarding systems used to produce
patient information, ensure that only authorized users may enter or correct any patient
information, explain that it is easy to identify the author as well as find the date and time
of all data entries. IT may provide information for an interrogatory or testify in court
being the custodian of the information systems. They may testify regarding the technical
infrastructure, system architecture, source applications and anything related to the
systems. Data Owners may testify about issues related solely from their department and
primary or direct custodians may provide information they directly had involvement in. A
B.A. or third party may testify and can include contractors or those who serve a variety of
functions associated with a partys information, but they are not parties to the litigation.
When being served with a subpoena for a patients medical records, one may be
overwhelmed by the amount of work and knowledge necessary to complete the task.
Identifying the correct patient, searching and retrieving the correct and relevant
information, and producing the records are a large process. However, knowing there are
several different teams working together as well as several resources to mirror will make
it easier to digest.

References:
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_036534.h
csp?dDocName=bok1_036534
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_028134.h
csp?dDocName=bok1_028134
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_031860.h
csp?dDocName=bok1_031860
http://journal.ahima.org/2010/10/21/preparing-for-discovery/
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_034052.h
csp?dDocName=bok1_034052