XYZ Hospital Southern OH Patient-Centered Care

Legal Health Record

Legal Health Record

Susan M. Vilardo
HCMT 1020-001
May 16, 2017
 XYZ Hospital Southern OH Patient-Centered Care
Legal Health Record

The Legal Health Record

The official business record generated for a healthcare organization. (i.e. XYZ Hospital)
It is the record that would be released upon receipt of a request.
Is the officially declared record of healthcare services provided
to an individual delivered by a provider.
Must identify the sources, medium, and location of the
the individually identifiable data that it includes.
Legal Health Record is a subset of the entire
patient data base.

WWW.HEALTHIT.GOV/ACCESS
ww.hhs.gov/hipaa/for-
professionals/privacy/guidance/access
 XYZ Hospital Southern OH Patient-Centered Care
Legal Health Record

Purpose of the Legal Record

The Legal Record is the official business record of XYZ HOSPITAL healthcare services
that are delivered by XYZ HOSPITAL for regulatory and disclosure purposes.
 XYZ Hospital Southern OH Patient-Centered Care
Legal Health Record

Custodian of the Legal Health Record

Health Information Manager in collaboration with Information Technology Personnel.
HIM professional oversee the operational function related to collecting, protecting, and
archiving the legal health record
Information technology staff manage the technical infrastructure of the electronic health record.
 XYZ Hospital Southern OH Patient-Centered Care
Legal Health Record

How HIPAA impacts the Legal Health Record background

HIPAA Healthcare Insurance Portability and Accountability Act of 1996
Privacy/Protection of patients rights
Federal statute, enacted, then amended in 2003
Establishes a consistent set of privacy and security rules that are designed to protect
the privacy of patients at the same time simplifying the sharing of health
information for legitimate purposes
The Privacy Rule in 2001 specifically addresses the protection of an individuals
personal health information
The operations, interactions, and daily business of the healthcare entity maintain
HIPAA compliance.
 XYZ Hospital Southern OH Patient-Centered Care
Legal Health Record

How HIPAA impacts the Legal Health Record

Patient health information is accessed through the Legal Health Record and is required
by law to comply with HIPAA provision or face and civil and/or criminal penalties.

Legal Health Records must remain confidential and cannot be accessed by people who
do not have proper authorization.

Disclosures made regarding a patients protected health information (PHI) without their
authorization is considered a violation of the Privacy Rule.
 XYZ Hospital Southern OH Patient-Centered Care
Legal Health Record

Documentation not included in the Legal Health Record

External Records and Reports that are generated outside of XYZ Hospital - examples other
providers external records referenced for patient care, records provided upon transfer; patient
generated records; personal health records

Committee Reports of Patient-Specific Care Decision document care implications and reference the
report

Administrative and Financial Data super bills/encounter forms; remittance advice; case
management records i.e. Birth and death certificate worksheets; correspondence concerning
requests for records; Databases containing patient information event history and audit trails;
Financials and insurance forms; Incident or patient safety forms; Notice of privacy practices;
Work lists

Derived Data aggregated or summarized from patient records so no means to identify patient
i.e. accreditation reports; anonymous patient data for research purposes; best-practice guidelines
created from aggregate patient data; statistical reports
 XYZ Hospital Southern OH Patient-Centered Care
Legal Health Record
Documentation not included in the Legal Health Record
Metadata indexing terms and attributes. Descriptive data that characterizes other data to create
clearer understanding of their meaning

Personal Health Record (PHR) universally available, lifelong resource of health information
individuals own and manage in the PHR, it is contained in a secure, private environment, with the
individual determining access rights. Separate from and does not replace the legal health record.

Shadow Records Copies of medical record documents generated by clinical departments as

working documents.

Of Special Note: Legal Health Record Policy Template

The determining factor in whether a document is considered part of the legal health record is not where the
information resides or its format, but rather how the information is used and whether it is reasonable to expect the
information to be routinely released when a request for a complete health record is received. The legal health record
excludes health records that are not official business records of the healthcare provider
pg.16, http://library.ahima/org/doc?oid=104008
 XYZ Hospital Southern OH Patient-Centered Care
Legal Health Record

Questions to Review for Understanding Pg. 1 of 2

1.) TRUE FALSE The Legal Health Record is the official business record for XYZ
Hospital.
2.) TRUE FALSE The Legal Health Record contains all of the records of the entire
patient data base.
3.) The Health Information Manager is the Custodian of the Legal Health Record and
collaborates this responsibility with__________________.
The patient
Information Technology Personnel
A designated Family member
Nursing Staff
 XYZ Hospital Southern OH Patient-Centered Care
Legal Health Record

Questions to Review for Understanding Pg. 2 of 2

4.) TRUE FALSE Legal Health Records do not fall under HIPAA confidentiality, so
the records can be accessed without proper authorization.

5.) Some documentation does not belong in the Legal Health Record. Below is a list
of items that are specific to documentation that does not belong in the Legal
Health Record for XYZ Hospital, except for one document that does belong in the
Legal Health Record. Find it and place a check next to it.
Shadow Documents/Working Documents
Committee Reports of Patient-Specific Care Decision
Financial Data - Financials and Insurance Forms
Clinical Record - Progress Notes
 XYZ Hospital Southern OH Patient-Centered Care
Legal Health Record

Questions to Review for Understanding

Answer Key

1.) True. The Legal Health record is the official business record generated for XYZ Hospital.
2.) False. LHR is a subset of the entire patient data base.
3.) The Health Information Manager is the Custodian of the Legal Health Record and collaborates this
responsibility with Information Technology Personnel.
4.) False. Legal Health Records must remain confidential and cannot be accessed by people who do not
have proper authorization.
5.) Clinical Record Progress Notes is a part of XYZ Hospital Legal Health Record documentation.
 XYZ Hospital Southern OH Patient-Centered Care
Legal Health Record

Resources:
Farenholz, C.G., Russo R., (2013). Documentation for Health Records,. Chicago, Illinois: American Health
Information Management Association (AHIMA).

AHIMA. Fundamental of the Legal Health Record and Designated Record Set. Journal of AHIMA 82, no.2
(February 2011): expanded online version. Accessed May 16, 2017,
http://library.ahima.org/doc?oid=104008

Avoid Violating HIPAA in 5 Easy Steps. Accessed May 17, 2017 from https://www.verywell.com/ways-
to-break-hipaa-compliance-2317112?print

Legal Health Record Policy Template. Provided by: The National Learning Consortium (NLC) Accessed
May 18, 2017 from https://www.healthit.gov/node/289
Legal Process and Electronic Health Records. Accessed May 18, 2017 from
http://library.ahima.org/doc?oid=59559
Your Health Information, Your Rights. Accessed May 8, 2017 from
WWW.HEALTHIT.GOV/ACCESS ww.hhs.gov/hipaa/for-professionals/privacy/guidance/access