Confidentiality, Privacy and Security

POLICY TO KEEP LEGAL DOCUMENTS OUT OF EHR

  • 1.  POLICY TO KEEP LEGAL DOCUMENTS OUT OF EHR

    Posted 5 days ago
    All -

    I'm fairly new to my position.  The previous compliance manager created a policy that all legal documents, which she defined as being any documentation about family, adoption, death, separation, and/or other business documents, be removed from the EHR and stored in a secure file location on our common drive.  This makes me uncomfortable but I can't find any documentation to state this is unacceptable.  Can anyone give me their impressions and/or documentation?

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    Sarah Jackson
    Compliance Manager
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  • 2.  RE: POLICY TO KEEP LEGAL DOCUMENTS OUT OF EHR

    Posted 4 days ago

    I am unaware of any standard however we keep the information in our records.  Adoption records might be handled differently as we are in the process of developing procedure on maintenance of these records.

     

    Lynn Boyes, RHIT

    Health Information Management Director,

    HIPAA Privacy Officer

    7010 S. Yale Ave | Tulsa, OK 74136
    lboyes@crsok.org 918.236.4135 direct line

    918.499.1598 fax

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  • 3.  RE: POLICY TO KEEP LEGAL DOCUMENTS OUT OF EHR

    Posted 4 days ago
    I am interested in this conversion. We also include these in our LMR and DRS with the presumption that these documents are used to demonstrate an individual's authority to consent for care or make decisions. However, due to the sensitivity of some of this documentation, there is some concern about it being routinely released. In the world of EHR's, HIM has less control of information sharing (i.e. more difficult to parse an individual document out; electronic disclosures without human intervention, etc.) Curious - how are others managing these types of documents? any struggles? solutions?

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    Lori Black, RHIA, CCS, CHTS-IM
    HIM Director
    INTEGRIS Health
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  • 4.  RE: POLICY TO KEEP LEGAL DOCUMENTS OUT OF EHR

    Posted 3 days ago
    I always become concerned when there is more than one place to pull from for a legal health record.   I believe that every effort should be made to make the patient's health record the repository for all relevant documentation.   How you define your designated record set or legal health record can determine whether or not you would further disclose the documentation upon request.  For example, we do not consider "correspondence" part of the legal health record, but it is maintain in the patient's health record.

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    Nancy Davis, MS, RHIA, CHPS
    Director of Compliance & Safety
    Door County Medical Center
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  • 5.  RE: POLICY TO KEEP LEGAL DOCUMENTS OUT OF EHR

    Posted 3 days ago
    Thank you for the responses.  This seems to confirm my feeling that these documents must be part of the EHR but secured (and/or named) in such a way as to differentiate them so they are not routinely released.

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    Sarah Jackson
    Compliance Manager
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