What Is the Legal Health Record
The legal health record, often abbreviated LHR, is the documentation generated by or for a healthcare organization that would be released upon a request for a patient's medical record, whether in response to a subpoena, court order, or patient request. The RHIA exam expects candidates to understand that the legal health record is distinct from the entire designated record set and distinct from the source systems that generate raw data.
Legal Health Record vs. Designated Record Set
The designated record set, defined under HIPAA, is broader and includes records used to make decisions about individuals, such as billing records and enrollment records, which a patient has a right to access. The legal health record is narrower and more specifically defined by organizational policy, representing the official business record disclosed for legal purposes. Some items in the designated record set, such as certain administrative or peer review materials, may be excluded from the legal health record.
Who Defines It
Each healthcare organization must formally define what constitutes its legal health record through policy, typically developed collaboratively by HIM, legal counsel, compliance, and information technology. This policy should specify the source system for each document type, the format in which it will be produced, and the retention period.
Metadata and System of Record
In an electronic environment with multiple clinical applications, organizations must designate an authoritative source, or system of record, for each data element to avoid conflicting versions of the same information appearing in different systems. Metadata, including timestamps, authorship, and amendment history, is considered part of the legal health record because it establishes authenticity and supports the integrity of the record in legal proceedings.
Amendments and the Legal Health Record
When a patient successfully requests an amendment, the original entry is not deleted; instead, the amendment is added with a clear link to the original entry, preserving the complete history for legal and clinical purposes.
Exam Tip
When a question asks which document would be excluded from a legal health record policy despite being part of the broader designated record set, look for items such as incident reports, peer review records, or draft documents that are not part of the official patient care record.
Key Takeaway
A well defined legal health record policy protects the organization during litigation by ensuring a consistent, defensible response to every record request.