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Legal Health Records

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Submitted By clpope88
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In 2006, AHIMA proposed the idea of a Legal Health Record as a set of health information that is compliant with specific laws and regulations. According to the Federal Rules of Evidence a health record identifies as a business record. This means the health record is created by a business and used for business purposes, as well as can be used for legal purposes, as it is presumed trustworthy. The Legal Health Record should also maintain any decisions make regarding the patient’s care, and the revenue needed by third-party payers. The general considerations when dealing with any format of a legal health record includes: purpose of record, compliance with laws and regulations, documentation, and rules of evidence. Also, much like paper legal health records, the considerations for electronic legal health records include: length of storage cost of storage, long-term usefulness, and long-term efficiency.

When discussing one of the general considerations of the Legal Health Record, there are a few laws and regulations that come to mind such as HIPAA and how it defines a designated record set, which is different from the Legal Health Record. HIPAA’s privacy rule defines the designated record set as “a group of records maintained by or for a covered entity that may include patient medical and billing records; the enrollment, payment, claims, adjudication, and cases or medical management record systems maintained by or for a health plan; or information used in whole or part to make care-related decisions.” (AHIMA, 2011). The designated record set is covers more information about the patient, as it contains all protected health information, while the legal health record focuses on information related to patient care. According to HIPAA, the designated record set is used to “clarify the rights of individuals to access, amend, restrict, and acquire an accounting of

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