What healthcare organizations define as a “legal” health record is becoming very important. The primary role of a health record is to keep a record of tests, treatments, and medications of a patient. A legal health record serves to identify what information constitutes the official business record of an organization for evidentiary purposes. (AHIMA, 2011) There are many issues that should be considered by a healthcare organization when defining the legal health record. One of the issues is how to store the health record. It used to be a legal health records were paper, but now electronic health records becoming more and more common. When electronic records are used, how to access and what they contain must also be considered. At Group Health Cooperative, headquartered in Seattle, Washington, patients have the ability to send emails directly to their physicians via the corporate website. Those emails are included in a patient’s legal health record. Storage cost and capacity is also something that should be considered. Paper files take up a lot of physical space and electronic records require server space. Both forms of storage carry considerable costs. HIPPA and state regulations demine how long health records must be stored. Currently the State of Washington suggests that health records are kept for 10 years and HIPPA regulations require records to be kept for six years. After considering what to keep, how to store it, and the amount of storage needed, then backup needs to be considered. This is very important for electronic records. A schedule for backing up records needs to be determined. The location where the backup is stored is crucial as well. Failure to comply with HIPAA can result in criminal penalties. Montana Code 41-1-402 2c which states that consent to the provision of health services and to control access to protected health care information by a health care facility or to the performance of health services by a health professional...
References: AHIMA. (2011). "Fundamentals of the Legal Health Record and Designated Record Set." . Journal of AHIMA, expanded online edition.
Adapted from Montana Code, Annotated 2009. Retrieved from http://data.opi.mt.gov/bills/MCA_toc/index.htm
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