Developing and Defining a Legal
Health Record Policy
By Cindy Zak, MS, RHIA, PMP, FAHIMA
YALE NEW HAVEN Health (YNHH) began implementing
the electronic health record (EHR) across four delivery networks in 2012. As the system moved to the electronic world,
it became evident that YNHH needed to address the issue
of defining the organization’s legal health record (LHR), a
subset of the designated record set (DRS).
YNHH began this initiative by creating a work group that
included members from information technology, Yale Medicine, and corporate health information management (HIM). At
YNHH, the new EHR vendor included both the university medical record and the system medical record as one component.
Yale Medicine is a separate entity from the YNHH, although Yale
University physicians (Yale Medicine) admit their patients to
Yale New Haven Hospital. Yale Medicine physicians are credentialed by the medical staff office. Their clinic medical records are
a component of the YNHH EHR. The residents and fellows further their training at Yale New Haven Hospital.
Clearly, with the EHR on the horizon, Yale New Haven
Health needed to define the LHR with YNHH and Yale Medicine stakeholders.
At YNHH, an EHR is maintained for each patient who is
evaluated or treated as an inpatient, outpatient, or emergency
patient at the delivery network and clinics, care centers, and
physician offices both for the Northeast Medical Group, the
physician entity, and Yale Medicine.
At the first work group meeting, the work group established
steps to defining the LHR. The group:
1. Determined what legal entities enforce regulations,
guidelines, standards, or laws within healthcare referencing the LHR definition and the LHR and/or designated record set (DRS).
2. Determined whether the records are created or referenced in the course of business at YNHH.
3. Addressed retention requirements.
4. Created a matrix that defines each document in the LHR
5. Established if the document is released to third parties in
response to legally permissible requests.
Designated Record Set
The DRS is defined by HIPPA. The DRS consists of the patient
medical records, billing records, patient enrollment, payment
information, claims, adjudication and cases, and medical
management record systems maintained by or for a health
plan; or information used in whole or in part to make care-related decisions.
YNHH determined it was important to define and differentiate explicitly the LHR from the DRS, which includes clinical
data stored on any medium and collected and directly used in
documenting healthcare or health status. The DRS is broader
than the LHR and includes all protected health information
and billing information.
YNHH’s policy defines the LHR and DRS as follows:
The LHR is the collection of information created and
maintained to document healthcare services provided to
a patient by YNHH in the course of the covered entity’s
business. The LHR is a subset of the DRS and is the record
that is released for legal proceedings or in response to requests for release of patient medical records.
The DRS is the group of records that include protected