Health Information Technologies and Processes

Legal Health Record

Lori L. Richter, Healthcare Management,Leadership,RHIA,CHPS,MA,CPHI10-18-2017 10:26

  • 1.  Legal Health Record

    Posted 10-18-2017 08:30
    ​​We are in the process of creating a policy that defines our Legal Health Record.  I was hoping that some of my AHIMA family would be willing to share their policy as it relates to the LHR?  I would appreciate any assistance you are willing to offer.

    Thank you!


    ------------------------------
    Deborah Parenti
    Director HIM
    ------------------------------


  • 2.  RE: Legal Health Record

    Posted 10-18-2017 09:04
    Hi, we have a draft one now we are also working on. Hoping to get it approved next week. Good luck!

    On 10/18/2017 at 8:29 AM, in message <0100015f2f7625cc-6d98d269-919a-43b8-b4f4-de2f2f83f2a6-000000@email.amazonses.com>, "Deborah Parenti via American Health Information Management Association" <Mail@ConnectedCommunity.org> wrote:
    We are in the process of creating a policy that defines our Legal Health Record.  I was hoping that some of my AHIMA family would be willing to...

    Health Information Technologies and Processes

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    Legal Health Record
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    Deborah J. Parenti, RHIT
    Oct 18, 2017 8:30 AM
    Deborah J. Parenti, RHIT
    We are in the process of creating a policy that defines our Legal Health Record.  I was hoping that some of my AHIMA family would be willing to share their policy as it relates to the LHR?  I would appreciate any assistance you are willing to offer.

    Thank you!


    ------------------------------
    Deborah Parenti
    Director HIM
    ------------------------------
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  • 3.  RE: Legal Health Record

    Posted 10-18-2017 10:26
    ​We define the legal health record within our DRS (Designated Record Set) Policy. It is more HIPAA-type language, but I believe as good as I've seen. But am ALWAYS looking for any additional or more detail outlined policies we could utilize as well. If anyone is willing to share as well that would be fabulous.  Here is a snippit:

    A.    Defining the Types of Records

     

    1. Designated Record Set (DRS) means a group record maintained by or for a covered entity that is the medical records and billing records about an individual; the enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan; or information used, in whole or in part, by or for the covered entity to make decisions about the individual. A DRS also includes wellness and disease management program files, laboratory test results, radiological images and clinical case notes.

     

    1. Record means any item, collection, or grouping of information that includes PHI and is maintained, collected, used, or disseminated by or for a covered entity.

     

    1. Legal Health Record (LHR) means the officially declared business record of healthcare services provided to an individual delivered by a provider. The LHR is used when responding to formal requests for information for legally permissible purposes. The LHR consists of specific documents and data elements in any medium that are collected and used for documenting healthcare services delivered.

     

    1. Medical Record is the chronological written record of an individual's examinations and treatments over time which may include a patient's history of illnesses, complaints, physical examinations, diagnoses, test results, medications taken, and therapeutic procedures administered.

     

    1. Billing Record is the record maintained for an individual that includes payment agreements, itemized bills for services rendered, account balances, claims made for payment, enrollment information, payment information, claims adjudication, collections activities, and documentation required to be maintained by federal and state law.

     

    1. Source File means the data from which interpretations, summaries, and notes are derived.

     





    ------------------------------
    Lori Richter
    OneCare EHR Compliance Director
    Catholic Health Initiatives
    ------------------------------



  • 4.  RE: Legal Health Record

    Posted 10-19-2017 17:18
    ​I am trying to create one as well, would love feedback from other Meditech Hospitals (CS).

    ------------------------------
    Stacey Goodenough
    Manager of Medical Records / Privacy Officer
    Wayne Memorial Hospital
    ------------------------------



  • 5.  RE: Legal Health Record

    Posted 10-19-2017 17:35

    I am also interested in hearing from other meditech hospitals.

     

    Kim Happ, RHIA

    St. Margaret's Hospital

    600 E. First Street

    Spring Valley, IL 61362

    DIrector, Medical Records, Registration/Scheduling, Switchboard

    Desk 815-664-1549

    Fax 815-664-1169

    khapp@aboutsmh.org

     

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  • 6.  RE: Legal Health Record

    Posted 10-20-2017 11:25

    Sounds like we are all in the same boat.  Hard to quantify in our almost EHR world.  AHIMA does have a great paper on the Legal Medical Record that has been updated.  Great definitions.  I am starting there...but haven't gotten much farther.

     

    Cherrell Cole, RHIT, CHPS, CCS

    HIMS Director and Privacy Officer

    Grand River Health | Rifle, CO

    970.625.6412 | Office

    NOTICE: This email message is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply email and destroy all copies of the original message including attachments and any other method of retention.





  • 7.  RE: Legal Health Record

    Posted 10-20-2017 08:58
      |   view attached
    ​I've attached ours....it took us a while with many iterations before we (HIM, Legal and Compliance) basically decided to keep it as simple as possible and instead of trying to lay everything out (which a previous policy did and was like 26 pages), we put things in a simple grid.

    ------------------------------
    Seth Katz
    Associate Administrator, Information Management
    Truman Medical Center
    ------------------------------

    Attachment(s)

    pdf
    Designated Record Set.pdf   105K 1 version


  • 8.  RE: Legal Health Record

    Posted 10-20-2017 13:29

    Thank you for sharing!

     

    Debbie Parenti, RHIT
    Director
    Health Information Management (HIM)
    Mon Health Medical Center
    1200 J. D. Anderson Drive
    Morgantown , WV 26505
    304-598-1914 Phone
    304-598-1369 Fax

    Connect With Us: MonHealth.com | Facebook | Twitter

    https://mhsnet.monhealthsys.org/Uploads/Public/Images/Logos%20-%20Buttons/logo-signature%20new.jpg

     

    Disclaimer: This e-mail and any attachments are confidential and may be protected by legal privilege and are intended only for the use of the addressee (s) named herein. If you are not the intended recipient, an addressee, or the person responsible for delivering this to an addressee, you are hereby notified that reading, using, copying, or distributing any part of this message is strictly prohibited. If you have received this e-mail in error, please return the e-mail to the sender and promptly delete the copy from your system.





  • 9.  RE: Legal Health Record

    Posted 10-23-2017 08:47

    This is a terrific conversation and thank you Seth and Sheila for sharing.

     

    One question I hope someone(s) can answer for me...

    We are a retirement community that provides 3 levels of care. Our patients often have health information overtime from an outpatient onsite medical practice, the assisted living residence and/or the skilled nursing facility. As you might imagine my grid is quite lengthy as I include the various assessments that nursing and providers complete that are required for patients at a specific level of care.

    My understanding is that we need to keep an account such as a spreadsheet of the medical records from when it was in paper form, the location of the paper information, the date the form transitioned to electronic and the database it resides in.  Are other orgs keeping this in their LHR/DRS policy or as a separate log that is referened by the policy?   

     

    Regards,

    Kristin Ferriter, MHA, RHIT, CPASRM

     

    Program Manager Compliance and Risk Management

    It's not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change- Charles Darwin

     

    CarolinaMeadows_updatedlogo

    Carolina Meadows, Inc.

    100 Carolina Meadows

    Chapel Hill, NC 27517-8505

    Phone: 919.370.7184

    Fax: (919) 929-7808

     

    CONFIDENTIALITY NOTICE: The information contained in this electronic message is privileged and confidential and is intended only for the use of the addressee(s). You are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this in error, please notify the sender by telephone and delete the message immediately. Thank you for your cooperation.





  • 10.  RE: Legal Health Record

    Posted 10-20-2017 11:12
      |   view attached
    Attached is our policy and procedure.  You will also need to consider all of your state laws and other regulations when you develop the policy.  Hope this helps.

    Regards, Sheila

    ------------------------------
    Sheila Zweifel
    HIM and Privacy Manager
    ------------------------------



  • 11.  RE: Legal Health Record

    Posted 10-20-2017 13:31

    Thank you for sharing!

     

    Debbie Parenti, RHIT
    Director
    Health Information Management (HIM)
    Mon Health Medical Center
    1200 J. D. Anderson Drive
    Morgantown , WV 26505
    304-598-1914 Phone
    304-598-1369 Fax

    Connect With Us: MonHealth.com | Facebook | Twitter

    https://mhsnet.monhealthsys.org/Uploads/Public/Images/Logos%20-%20Buttons/logo-signature%20new.jpg

     

    Disclaimer: This e-mail and any attachments are confidential and may be protected by legal privilege and are intended only for the use of the addressee (s) named herein. If you are not the intended recipient, an addressee, or the person responsible for delivering this to an addressee, you are hereby notified that reading, using, copying, or distributing any part of this message is strictly prohibited. If you have received this e-mail in error, please return the e-mail to the sender and promptly delete the copy from your system.





  • 12.  RE: Legal Health Record

    Posted 10-23-2017 08:50

    I am also interested in hearing from other Meditech hospitals.

     

     

    Zona K. Babb, RHIT | Health Information Manager

    Direct: 859-235-3528 | Fax: 859-235-3694

    Harrison Memorial Hospital | 1210 KY Highway 36 East, Cynthiana, KY 41031

    zbabb@hmhosp.org

     

     






  • 13.  RE: Legal Health Record

    Posted 05-08-2019 10:13

    Following up to see if anyone has since defined their LH and/or DR and are willing to share.

    Thanks.



    ------------------------------
    Deanna Heinrich
    Director of HIM/Privacy Officer
    ------------------------------



  • 14.  RE: Legal Health Record

    Posted 05-08-2019 10:31
    I'm interested, too. Thank you.

    Katherine Valeri, RHIT
    Medical Records Consultant
    KV Health Information Management Consulting
    832-764-3522






  • 15.  RE: Legal Health Record

    Posted 05-08-2019 10:51
      |   view attached
    I believe I posted this on here once before, but here is our policy for what is in the LMR vs. DRS.

    ------------------------------
    Seth Katz
    Associate Chief Information Officer
    Truman Medical Center
    ------------------------------

    Attachment(s)

    pdf
    Designated Record Set.pdf   105K 1 version