Defining the Legal Health Record
The legal health record, often abbreviated LHR, refers to the documentation generated by or for a healthcare organization that is considered its official business record in response to legal requests, subpoenas, or evidentiary purposes. The LHR represents what the organization is prepared to produce upon a legal request for a complete patient record.
Legal Health Record Versus Designated Record Set
The designated record set, defined under HIPAA, is broader than the legal health record. It includes medical and billing records used to make decisions about individuals, and patients have a right of access to their designated record set. The legal health record, by contrast, is an organization-specific definition of what constitutes the official record for legal purposes and may exclude certain items included in the designated record set, such as raw data from ancillary systems, quality assurance documents, or provider peer review records not intended for release.
Components of the Legal Health Record
Typical components include:
- Patient identification and demographic information
- History and physical examinations
- Physician orders and progress notes
- Diagnostic test results, including laboratory and imaging reports
- Consent forms and advance directives
- Discharge summaries and operative reports
Developing a Legal Health Record Policy
Organizations must formally define their legal health record through a written policy developed collaboratively by HIM, legal counsel, compliance, and clinical leadership. The policy should specify what documents are included, the source system for each document type, and the individual responsible for authentication of entries.
Metadata and Audit Trails
In electronic health record environments, metadata such as timestamps, user identification, and audit trails are essential components supporting the legal health record's authenticity and integrity, particularly when records are challenged in litigation.
Litigation Considerations
When a healthcare organization receives a subpoena or is named in litigation, HIM professionals must ensure that only the properly defined legal health record, and not extraneous internal documents, is produced. Improper disclosure of protected internal documents, such as incident reports or peer review materials, may waive legal privileges those documents would otherwise hold.
Amendments and Corrections
Patients have the right to request amendments to their health record. Amendments must follow a formal process that preserves the original entry while clearly documenting the requested change, maintaining the integrity of the legal record.
The HIM Role
HIM professionals lead the development and maintenance of legal health record policies, coordinate responses to legal requests, and ensure record integrity is preserved across paper and electronic systems.
Conclusion
A clearly defined legal health record policy, developed with input from legal and clinical stakeholders, protects the organization during litigation while ensuring appropriate and complete disclosure of official health records.