Legal Health Record Policy Template

The material in these guides and tools was developed from the experiences of regional extension center staff in the performance of technical support and ehr implementation. Ahima recommends legal counsel. Due to the number of variables affecting the length of time a provider should keep a medical record it is recommended that your retention policy gets reviewed by legal counsel.

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Legal health record policy template. It is shs policy to apply effective and cost efficient management. Technology acquisitions and workflow improvements. Record retention and destruction policy 1 purpose the purpose of this policy is to ensure that necessary records and documents of are adequately protected and maintained and to ensure that records that are no longer needed by insert name of organization or are of no value are discarded at the proper time. This policy applies to all sample health system shs employees with responsibilities for the creation use maintenance retention preservation and disposal of shs records.

The purpose of this policy is to identify the legal health record of organization for business and legal purposes and to ensure that the integrity of the legal health record is maintained so that it can support legal and business needs. Review the policy during the approval process. Ahima developing a legal health record policy members of ahima ehr practice council. Legal ehr policy template developed by members of the ehr practice council may 2007 how to use this tool health care providers must maintain a health record that documents care and services provided to an individual.

Legal health record lhr it is the policy of uconn health to create and maintain health records that in addition to their primary intended purpose of clinical and patient care use will also serve the business and legal needs of uconn health. Organizations legal electronic health record definition. This policy is also for the purpose. The medical record whether in paper or electronic format to include patient identifiable source information such as photographs films digital images and fetal monitor strips when a written or dictated summary or interpretation of finding has not been prepared.

Additionally clinical decision making tools such as alerts and pop ups are not part of the legal medical record. Legal medical record source data from outside of the legal medical record administrative data derived data drafts audio and video recordings of patient encounters works in progress and audit trails. Of optimal electronic signature approaches organizations should identify gaps for future. If technology limitations preclude implementation.

Records management and retention. Review your documented medical record retention policy with legal counsel. It is the policy of uconn health to maintain health records that will not. In addition to their clinical purposes health records must also be maintained for business and evidentiary purposes.

Policy template to determine health care organizations legal health records and to ensure integrity for legal and business purposes.