AHIMA Issues Guidelines for Defining ‘Legal Health Records’

The American Health Information Management Association has issued new guidelines to help health care organizations reassess their definitions of what constitutes a "legal health care record" in light of recent advances in medical records technologies, AHA News Now reports. Because laws vary from state to state, AHIMA's "Guidelines for Defining the Health Record for Legal Purposes" is intended to offer "common principles" to follow in creating a definition. The guidelines present a core definition of the legal medical record as "individually identifiable data, in any medium, collected and directly used in and/or documenting health care or health care status." The guidelines also give special consideration to the use of electronic medical records, telemedicine and patient-created personal health records. For example, personal health records -- medical information compiled and managed by patients or family members -- normally should not be considered part of the legal health record because they do not pertain to the official business of the helath care organization. A personal health record would, however, constitute part of a patient's legal medical record in instances where the patient gave the information to a provider, who then used it to "provide patient care services, review patient data, or document observations, actions or instructions." This would include patient records such as daily glucose or insulin levels for diabetics (AHA News Now, 10/8).