Understanding the Legal Health

Record
Mary Kobren

XYZHospital

What is the Legal Health

Record?
The legal health record is the documentation of
healthcare services provided to an individual. The
definition of the legal health record must be
defined by the organization. The legal health
record documents the decisions and services
made in a patients care.

Who is the custodian of the

Legal Health Record?
The custodian of the legal health record is the
health information manager in collaboration with
information technology personnel.
The health information manager is responsible for
the procedures for collecting, protecting, and
archiving the legal health record
The information technology staff are responsible
for the systems that store and process the legal
health record.

What purpose does the Legal

Health Record Serve?
The legal health record defines what an
organization defines as the official business record
for health services provided to an individual for
legal evidence purposes.

How does HIPAA impact the

Legal Health Record?
HIPAA regulations require organizations that
maintain health information records must
implement administrative, physical and technical
safeguards that reasonably and appropriately
protect the confidentiality, integrity, and availability
health care information that it creates, receives,
maintains, or transmits.

What documentation that is not

included in the Legal Health
Record?
Health information that does not include decision
making about the individual
Psychotherapy notes
Employer Records

Test your understanding?

1. Does a organization or business that deals with
making decision on a persons health have to
have a Legal Health Record?
2. Can a patient get a copy of their Legal Health
Record?
3. Is it possible for a legal Health Record to be used
during a court proceeding?
4. Does the Health Information Record contain all
documented notes on an individual?
5. Who defines what is contained in the Health
Information Record?
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References
AHIMA e-HIM Work Group on the Legal Health
Record. "Update: Guidelines for Defining the Legal
Health Record for Disclosure Purposes." Journal of
AHIMA 76, no. 8 (Sept. 2005): 64A?G. Available
online in the AHIMA Body of Knowledge at
www.ahima.org.