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Defining the Legal Health Record
Defining the Legal Health Record
The medical field is a fast-evolving field of care. The legal Health Record is a crucial part of this
evolving time. From paper charting to EMR and HER, there has been left room for error, missing
documentation and loss of records. In this report we will cover what defines a Legal Health Record.
Defining a Health record is not impossible however it can be challenging. To make a Health
record you need a patient, you need to see that patient and input the patients Demographics followed
by the clinical portion of the chart. In order for that to happen there needs to be office visits, tests etc.
done. Each facility has a duty to the accuracy of each patient’s medical documentation. That is what can
help to define a Legal Medical Record. The record is only as good as the facility.
Medical records contain two separate entities in a patient chart. Primary and secondary.
A legal Health Record should contain both. The primary being all clinical notes, reports, tests, results,
encounters etc. While the secondary part of the chart should contain all the patients Demographics
information, insurance etc. Any legal Medical Health record should have all the above information.
When receiving medical records from another facility, those like that rest are confidential and
should be carried as such, they are vital to the patient’s chart and should be placed in the chart
accordingly and timely.
However, it’s been told that some organizations need to consult with legal
counsel to determine if outside records should be combined with the said facilities documents.
In order for an EHR to be considered a Legal Health Record, a couple concepts should be
considered. Such as, how new is the software being used, are there glitches in the software prohibiting a
through and complete chart. Documents signed off by a health care provider, how documentation is
created and interacts with billing and claims as well as other factors.
Jodi Thomas
