Health Information Technologies and Processes

Legal Health Record - escripts

  • 1.  Legal Health Record - escripts

    Posted 05-13-2019 12:44
    ​I am curious if other facilities include any electronic prescriptions and the receipt confirmation from the pharmacy to which the prescription was sent  in your output of the legal health record. We have the medication order in the output but not an "image" of the script that was electronically filed to the pharmacy nor documentation of it's receipt by the pharmacy. In the previous paper process we did not keep a photo copy of prescriptions given to patients. Is there a legal need to produce this as part of the legal health record output?

    JoEllen Cook
    Director Health Information Management
    Mercy Medical Center

  • 2.  RE: Legal Health Record - escripts

    Posted 05-14-2019 08:13
    We do not keep an "image" of the prescription, nor  do we include the audit trail in the output record. We can get the details, if we are specifically asked to produce it.

    Kathryn Wood, RHIA
    Assistant Director of Information Systems/Privacy Officer
    War Memorial Hospital

  • 3.  RE: Legal Health Record - escripts

    Posted 05-14-2019 09:06
    We do keep an image of prescriptions but we do not include them in our legal medical record and routine requests.

    DeAnn Tucker
    Him Director