Practical advice and policy guidance to manage patient records for legal scrutinyBy most definitions, a health record is the set of documents used to provide optimum patient care and document the patient's progress across the continuum of care, generate a bill for appropriate reimbursement, and conduct audits and research.
Whether on paper, in a hybrid format, or completely electronic, the medical record is the industry Bible--the source from which all other records and documents are generated.
But medical records also serve as legal documents. At any time, a court may require a record as part of a legal proceeding, and you must be ready to provide it.
"The Legal Health Record Companion: ""A case study approach" is a hands-on resource tool that shows you how to define and develop health records that meet legal requirements. You'll learn how to use the health record appropriately and efficiently--from the legal point of view--as well as from the more familiar patient safety and common-sense perspective.Developed from field experience
Authors Deborah Adair and Karen Griffin use actual case scenarios from Massachusetts General Hospital and Brigham & Women's Hospital in Boston to demonstrate how to put responsibility into best practice when developing sound and reliable legal health records.You will learn how to
- document a true "reflection" or evidence of a patient's true status
- create a legal health record definition that works for your facility
- protect the legal health record
- maintain the legal health record in a manner that ensures that the most accurate, well-organized, and accessible health information is available for the care and treatment of the patient
- employ best-practice operational standards
The authors also include sample policies your can customize for your organization, a pertinent question and answer section, and a glossary of frequently used terms.What makes it a "legal" record?
It's not easy to define what comprises a legal health record. Every organization has its own procedures for which documents are added to its records. Forms and policies differ, even within the organization.
Professional organizations suggest record-keeping practices for clinical staff. Regulatory agencies add another level of record criteria. The HIPAA privacy and security rules place mandates on what defines a record.
Ultimately it is your organization's responsibility to define its legal health record. That definition will change and you will continue to massage the definition as long as you have to--especially as you convert to electronic health records--to maintain the integrity of information you keep.
