Question

Use pages 222-223, especially Table 9.1, and the Legal Health Record Definition and Role from AHIMA to compose an original post considering and examining these questions: 1. What is a "legal health record (LHR)?" 2. Does the LHR contain every single piece of information about a patient? If so, why? If not, why not? 3. If a subpoena is received for a patient who had a heart attack, would the ECG tracing be provided? If so, why? If not, why not and what would be provided related to the ECG? 4. Would a patient's itemized bill be part of the LHR? Why or why not? See the attached rubric for how this assignment will be graded.

Answer 1

1. A legal health record (LHR) is the documentation of patient health information that is created by a health care organization. The LHR is used within the organization as a business record and made available upon request from patients or legal services.

There is no specific set of regulations for legal health records however, they must meet standards set by federal and state laws. After meeting these basic standards, it is up to the discretion of the individual healthcare organization to decide what is and is not appropriate to reveal. The legal health record serves to identify what information constitutes the official business record of an organization for evidentiary purposes. The legal health record is a subset of the entire patient database. The elements that constitute an organization's legal health record vary depending on how the organization defines it.