Creating a Legal Health Record
Definition
By Kelly McLendon, RHIA, CHPS
AS A MEDICAL record custodian, it is the HIM professional’s re- sponsibility to address legal EHR issues proactively rather than reactively. Defining an organization’s legal health record (LHR) in advance will enable an entity to be prepared for both routine and high-stress record requests. Every HIM department should establish a legal health record definition project in order to cre- ate or audit their legal EHR processes. The following excerpt from Kelly McLendon’s book The Legal Health Record: Regulations, Policies, and Guidance outlines the steps organizations can take to define their legal health record. LHR Definition Project Steps
Several high-level activities comprise LHR definition projects.
Adequate time should be allocated to define LHR in your organization. The timeframes are generally long, and these projects are typically performed by staff members who are already
overburdened and may be responsible for multiple facilities.
However, the importance of managing the risks and liabilities
requires that time is spent defining each organization’s LHR.
At each step in the process, there are requirements for learning
new concepts and in researching how other sites have solved
similar problems.
There is much to consider when creating an organization-wide LHR definition project. The following steps are based upon
common and standard best practices.
Step 1: Determine the LHR stakeholder team.
The stakeholder team will drive the creation and undertake the
LHR definition project, and be responsible for its continued
maintenance. It is highly recommended the record custodian
be in charge or included as a member of the team. Adequate
control of records is a primary consideration in managing your
LHR. Organize your materials into notebook(s) or an electronically accessible format available to all parties who will need access to it. Determine who will be charged with various segments
of the operation and maintenance of LHR-related processes going forward.
In the first steps of undertaking a LHR definition, create a process to move the project along according to formal rules adopted by the enterprise. Creating a definition in a small, physician
practice office is simple enough—stakeholders are all nearby
and there may be few of them. But the larger the organization,
the more complex the electronic record environment and the
harder the LHR definition is to achieve.
Therefore, using formal project methodology is highly recommended. LHR definitions are enterprise-wide in nature and are
not typically the product of a single individual, unless the organization is quite small. Careful review of potential stakeholders
will ensure that appropriate parties are selected to work on the
project.
It is up to record custodians and risk and legal staffs to facilitate the project with carefully selected project team members.
Step 2: Determine strategy and plan for the LHR definition proj-
ect, and get executive sponsorship and empowerment.
Get executive and other appropriate sponsorship and empowerment. Determine timelines, stakeholders, and strategies for
accomplishing the various required tasks. It is recommended
that the project timeline be embedded within the critical path of
the organization’s overall implementation of an EHR solution.
Be sure to determine who will vet this entire process and when.
Project governance and leadership is another important as-
