LEGAL STANDARD MEDICAL RECORD

 PURPOSE
To establish guidelines for the contents, maintenance, and confidentiality of patient Medical Records that meet the requirements set forth in federal and State laws and regulations, and to define the portion of an individual’s healthcare information, whether in paper or electronic format, that comprises the medical record. Patient medical information is contained within multiple electronic records systems in combination with financial and other types of data. This policy defines requirements for those components of information that comprise a patient’s complete “Legal Medical Record.”
DEFINITIONS
Medical Record:  The collection of information concerning a patient and his or her health care that is created and maintained in the regular course of UC__ business in accordance with UC__ policies, made by a person who has knowledge of the acts, events, opinions or diagnoses relating to the patient, and made at or around the time indicated in the documentation.  
·         The medical record may include records maintained in an electronic medical / record system, e.g., an electronic system framework that integrates data from multiple sources, captures data at the point of care, and supports caregiver decision making.
·         The medical record excludes health records that are not official business records of UC, such as personal health records managed by the patient.
Each Medical Record shall contain sufficient, accurate information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers. The information may be from any source and in any format, including, but not limited to print medium, audio/visual recording, and/or electronic display.  

 The Medical Record may also be known as the “Legal Medical Record” or  “LMR” in that it serves as the documentation of the healthcare services provided to a patient by a UC__ hospital, clinic, physician or provider and can be certified by the UC__ Record Custodian(s) as such. . 
The Legal Medical Record is a subset of the Designated Record Set and is the record that will be released for legal proceedings or in response to a request to release patient medical records. The Legal Medical Record can be certified as such in a court of law. Designated Record Set (“DRS”):  A group of records that include protected health information (PHI) and that is maintained, collected, used or disseminated by, or for, a covered entity (e.g. the UC Medical Center) for each individual that receives care from a covered individual or institution.  The DRS includes:
1.       The medical records and billing records about individuals maintained by or for a covered health care provider (can be in a business associate’s records);
2.       The enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan; or
3.       The information used, in part or in whole, to make decisions about individuals.

Any research activities that create PHI should be maintained as a part of the DRS and are accessible to research participants unless there is a HIPAA Privacy Rule permitted exception.

Protected Health Information (“PHI”):  PHI is individually identifiable health information that is transmitted or maintained in any medium, including oral statements. 

Authentication:  The process that ensures that users are who they say they are.  The aim is to prevent unauthorized people from accessing data or using another person's identity to sign documents.
Signature:  A signature identifies the author or the responsible party who takes ownership of and attests to the information contained in a record entry or document.
Clinic Record / Shadow File:  A folder containing COPIES ONLY of information from the medical record used primarily by clinicians in their office or clinic setting. These COPIES of the relevant documents from the original medical record are NOT part of the legal medical record.
Macros:  Macros allow a provider to record and replay a series of typed characters or other keystrokes (e.g., hot keys, one or more keys at the same time, or one-word commands) in a manner that makes it possible for a physician or a provider to quickly document an entire medical note while avoiding the cost of transcription and/or the time of repetitive documentation.

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