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DEFINING THE MEDICAL RECORD: RELATIONSHIPS OF THE LEGAL MEDICAL RECORD, THE DESIGNATED RECORD SET, AND THE ELECTRONIC HEALTH RECORD.

Not so long ago, defining the "medical record" was simple. It was the paper chart--volume upon volume that captured the serial, dutifully recorded events of a person's health care at a hospital or physician's office. Entries were typically handwritten, dated and timed, and signed in ink with title (...

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Published in:Perspectives in Health Information Management Vol. 19; no. 4; pp. 1 - 11
Main Authors: Floyd, Phyllis T., Oates, Jim C., Acker, Julie W., Warren, Robert W.
Format: Journal Article
Published: American Health Information Management Association Fall2022
Online Access:View this record in EBSCOhost
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      dt: Fall2022
      vid: 19
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      pub: American Health Information Management Association
      place: Chicago, Illinois
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        atl: DEFINING THE MEDICAL RECORD: RELATIONSHIPS OF THE LEGAL MEDICAL RECORD, THE DESIGNATED RECORD SET, AND THE ELECTRONIC HEALTH RECORD.
      aug:
        au:
          Floyd, Phyllis T.
          Oates, Jim C.
          Acker, Julie W.
          Warren, Robert W.
        affil: Retired HIM director at the Medical University of South Carolina
      sug:
        subj:
          Electronic Health Records
          Evidence, Legal
          Health Information Management Personnel Education
          Technology
          Health Care Errors
          Medical Informatics
          Health Insurance Portability and Accountability Act
          Data Security
          Privacy and Confidentiality
          Organizational Policies
          Professional Role
          Information Storage
          Information Retrieval
      ab: Not so long ago, defining the "medical record" was simple. It was the paper chart--volume upon volume that captured the serial, dutifully recorded events of a person's health care at a hospital or physician's office. Entries were typically handwritten, dated and timed, and signed in ink with title (i.e., authenticated). Errors were easily identified by an authenticated strike-through. Similarly, the paper chart was synonymous with the legal medical record (LMR). In other words, a patient's paper chart was that patient's LMR by definition, even if critical data was omitted or irrelevant data was included. Fast-forward to 2021 and the use of technology for capturing the record of a patient's care. Technology has brought new challenges as well as successes. For example, pervasive and persistent mythologies include that 1) a patient's electronic health record (EHR) is the LMR, and 2) patient-specific EHR printouts to paper or disc--or displays on monitors--are necessarily equivalents to the paper chart of the 1980s. Neither are true. We now must define at the outset what is included in the LMR/designated record set to ensure the accuracy of what is retained and released.
      pubtype: Academic Journal
      doctype: Journal Article
      ougenre: Article
    language: English
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