health information along with business information that
is maintained, collected, used, or disseminated by or for a
covered entity for each individual that receives care.
The primary reason for the development of the LHR policy
was to identify those documents that YNHH and Yale Medicine would release for formal business and legal purposes and
to ensure that the integrity of the health record is maintained
so that it can support business and legal needs.
In reviewing Connecticut state law, the LHR was not addressed from a state law perspective. The work group’s primary references were the AHIMA practice brief and the HIPAA
regulations referencing the DRS.
Defining the components of the LHR required the work
group to inventory the documents maintained in the EHR
that included scanned documents. The work group reviewed
each document and determined if that document was referenced and used to document healthcare services provided to
The work group wanted to keep the matrix simple to include as an attachment to the policy for all to reference. The
LHR could be generated by departments other than HIM,
The regulatory department when the Department of
Public Health and the Joint Commission perform site
IT when depositions occurred.
The privacy officer when working with patient complaints.
The work group limited the matrix to include the document name and a column defining the document as the DRS
and/or LHR. There are a total of three columns in the final
matrix that are posted on the system intranet. All the documents included in the matrix are components of the EHR
Overall, the policy applies to all uses and disclosures of
the health record for administrative, business, or evidentiary purposes. It encompasses reviewing documents that
were recorded on a variety of media including, but not limited to, electronic, paper, digital images, video, and audio.
It was the intent of the work group not to compromise the
LHR and to include all documents that are created and authenticated in the ordinary course of the hospital’s business
during the patient’s encounter.
The matrix also addressed external content used in decision-making and care of the patient, such as record forms
and reports from other healthcare providers.
YNHH has a policy that requires physicians to identify which
external documents they referenced in the care of the patient.
Those are the documents that are scanned into the EHR.
Numerous documents required review and consensus. The
following documents were discussed and it was then determined if they were part of the LRH and/or DRS:
EKG and EEG tracings
Fetal monitor strips
LHR and DRS components:
Personal health records (PHR) at the time the PHR was accepted by the provider
Patient portal messaging was accepted both in the LHR
Physician queries were also part of the LHR
Documents that were not included in LHR nor DRS:
Employee health records
The LHR is printed when the button to print is selected in the
EHR. This was programmed by IT. It is not uncommon for the
regulators to ask for the LHR policy and matrix when they are
onsite and reference it throughout their visit.
IT ensures appropriate access to the LHR and DRS occurs in
compliance with the delivery networks’ archiving and retention schedule.
An ongoing quality control program is in place to monitor
timeliness and accuracy of scanning and indexing. Where decentralized scanning is deployed, HIM remains accountable
for all aspects of the quality control and verifies the completeness of the medical record in accordance with established
All medical records are completed within 21 days following
discharge, with a less than one percent suspension rate across
all YNHH networks. Audit trails of user access, action, and
date of action to the EHR are monitored by the I T security area.
The LHR and DRS policy is reviewed on an annual basis and
updated as needed. ¢
Cindy Zak ( email@example.com) is the executive director, revenue services,
Yale New Haven Health.
YNHH determined it was important to define and differentiate the LHR
from the DRS, which includes clinical data stored on any medium and
collected and directly used in documenting healthcare or health status.