have to go to four or five different EHRs or systems to retrieve
all the requested data. Having a matrix that can serve as a table of contents to where records live can be a key to unlocking
the data siloes, Richter says.
Legal Health Record Revisited
As the term itself suggests, the LHR’s job is to serve as a healthcare organization’s business and legal record, and as noted
previously, document the services provided as legal testimony
regarding the patient’s illness or injury, response to treatment,
and caregiver decisions. Several of the organizations queried
for this article define their own LHRs based on AHIMA Practice Briefs and guidance on the topic, including DeMasters.
“I think there needs to be a basic definition so there is an
understanding of the DRS versus the legal health record and
examples of each—I would refer to AHIMA documents [in-
cluding Practice Briefs],” DeMasters says. “To write a policy
to capture all things pertaining to the legal health record is
It is also crucial.
At MRO, a release-of-information vendor, Bowen works
closely with providers to make sure they know the difference
between the DRS and the LHR because of the massive file size
and volume of data that must be released.
“I’m just surprised at the number of facilities who don’t understand the difference between what the DRS should be and
contain—some simply say they [DRS and LHR] are one and the
same—and they are not one and the same,” Bowen says.
She adds that the only time information should be released
from the DRS is if it’s to the patient or a patient-directed request. For any other general ROI purpose, it’s going to come
from the LHR, in Bowen’s view. If an organization decides that
everything in a patient’s EHR is part of the LHR, they may have
to release a radiology image to a patient who doesn’t know how
to read an X-ray or an MRI image.
If a facility’s LHR policy has too much overlap with the DRS,
they may be stuck releasing all sorts of images the average patient is unable to interpret. ¢
1. AHIMA. “Fundamentals of the Legal Health Record
and Designated Record Set.” Journal of AHIMA 82, no. 2
(February 2011): expanded online version.
Mary Butler ( firstname.lastname@example.org) is associate editor at the Journal of
CDI Audits and Assessments
In Search of the EHR’s
Designated Record Set