LEGAL HEALTH RECORDS

IN-SERVICE
PRESENTED BY: JAMIE BROWN

WHAT IS THE LEGAL HEALTH RECORD?

IT IS DIFFICULT TO DEFINE LEGAL HEALTH RECORDS, BECAUSE IT VARIES
FACILITY TO FACILITY.
NO MATTER HOW WE DEFINE IT, IT MUST REPRESENT OUR BUSINESS AND
LEGAL NEEDS.

WHO IS THE CUSTODIAN OF THE LEGAL

HEALTH RECORD?
THE LEGAL HEALTH RECORDS BELONGS TO THE HEALTHCARE PROVIDER OR
THE HOSPITAL THAT CREATED THEM.
AFTER CERTAIN FEDERAL REQUIREMENTS ARE MET, IT IS THEN UP TO THE
HEALTHCARE PROVIDER TO DECIDE WHAT CAN AND CAN NOT BE RELEASED.

WHAT PURPOSE DOES THE LEGAL HEALTH

RECORD SERVE?
DESPITE WHAT MANY THINK THE HEALTHCARE INDUSTRY IS A BUSINESS, AND
LIKE ANY OTHER BUSINESS WE HAVE TO HAVE DOCUMENTATION.
WE ALSO HAVE THE FOR LEGAL REASONS SUCH AS; BILLING, CAN SERVE AS A
LEGAL TESTIMONY IN COURT, AND SUPPORTS DECISION MADE.

HOW DOES HIPAA IMPACT THE LEGAL

HEALTH RECORD?
HIPAA HELPS PREVENT FRAUD AND ABUSE IN REGARDS TO PAYMENTS.
REGULATES THE STANDARDS OF WHAT WE MUST REPORT TO THE FEDERAL
GOVERNMENT.
PROTECTS PATIENTS PRIVACY.

DOCUMENTATION THAT SHOULD NOT BE IN

THE LEGAL HEALTH RECORD.
PENDING REPORTS
AUDITS
METADATA
VERSIONS
RAW DATA THAT HAS TO BE INTERPRETED
EDUCATION RECORDS
BUSINESS ASSOCIATE RECORDS.
EMPLOYER RECORDS
AND MORE

REVIEW QUESTIONS
IS THERE A FULL DEFINITION OF THE LEGAL HEALTH RECORD?
TO WHOM DOES THE LEGAL HEALTH RECORD BELONG?
DOES THE LEGAL HEALTH RECORD SERVE ANY OTHER PURPOSE, ASIDES
FROM BILLING?
WHAT DOES HIPAA REGULATE WITH THE LEGAL HEALTH RECORD?
NAME SOMETHING THAT ISNT INCLUDED IN THE LEGAL HEALTH RECORD.

REFERENCES:
OUR TEXTBOOK: DOCUMENTATION FOR HEALTH RECORDS
CHAPTER 2 POWERPOINT
HTTP://SEARCHHEALTHIT.TECHTARGET.COM/DEFINITION/LEGAL-HEALTHRECORD
HTTP://LIBRARY.AHIMA.ORG/XPEDIO/GROUPS/PUBLIC/DOCUMENTS/AHIMA/BOK
1_048604.HCSP?DDOCNAME=BOK1_048604
HTTP://WWW.HRSA.GOV/HEALTHIT/TOOLBOX/HEALTHITADOPTIONTOOLBOX/PRI
VACYANDSECURITY/HIPAAIMPACT.HTML