THE LEGAL RECORD

OF XYZ HOSPITAL

By: Ulela Mae Hill

DEFINING LEGAL RECORD

Offi cial business record created by or for health care
organization
Documentation of services given to patients
throughout their health care delivery
Includes information used to support decisions about
the patients plan of treatment
Subset of patients entire database
Must meet standards of state and federal laws
Disclosed to others outside of organization by request
from patients and legal services

CUSTODIAN OF LEGAL RECORD

Health information manager
Manages the collecting, protecting, and archiving of the
legal health record

Information technology personnel

Manages the technical infrastructure of the electronic
health record

PURPOSE OF THE LEGAL RECORD

Support decisions made in patients care
Support the revenue sought from third-party payers
Document the services provided as legal testimony
Serves as organizations business and legal record

HIPAA IMPACT
HIPAA requires us to identify our designed record
set

Legal health record is subset of designated record set

HIPAA requires us to defi ne data and the documents

that identify how the records are maintained.
We must meet requirements for a business record
used for legal purposes.

DOCUMENTATION NOT INCLUDED IN

LEGAL RECORD
Administrative data

Patient identifi able documentation

Consents for treatment
Research forms
Audit trails
Birth and death certifi cates worksheets

Derived data
Factual details taken and summarized from a group of
health records.
Statistical reports
Accreditation reports
OASIS reports

DOCUMENTATION NOT INCLUDED IN

LEGAL RECORD CONTD
Aggregate Data
Information that is piled into data summaries
Examining trends
Making

UNDERSTANDING THE LEGAL

RECORD
What is the offi cial business record of health
information called?
What information is included in the legal health record?
How does the health information manager and
information technology personnel manage the legal
health record?
What are the three purposes of the legal health record?
What are the three types of data not included in the
legal health record ? Give example of each.

REFERENCES
Fahrenholz, C. G., & Russo, R. (2013). Documentation
for health records. AHIMA.
Legal Process and Electronic Health Records. (2005,
October). Retrieved May 21, 2016, from
http://library.ahima.org/doc?
oid=59559#.V0DlP5ErKM9
What is legal health record? (2009). Retrieved May
21, 2016, from
http://searchhealthit.techtarget.com/defi nition/legalhealth-record