Maintaining a Legally Defensible Health Record Legal Aspects of Healthcare Maintaining a Legally Defensible Health Record Maintaining a Legally Defensible Health Record Integrity – accuracy and completeness Authentication Accuracy Authorship Use of abbreviations Legibility Changes to the record Timeliness and completeness

Verification of the source of a message Identification of author Legal Aspects of Healthcare Maintaining a Legally Defensible Health Record Authentication Verification of the source of a message Identification of author Assignment of responsibility to the author

Authentication of electronic health records Legal Aspects of Healthcare Maintaining a Legally Defensible Health Record Authentication Authentication of electronic health records Considerations Authenticity Integrity Non-repudiation E-signatrues Digital signatures Computer-key

Authentication of paper health records Legal Aspects of Healthcare Maintaining a Legally Defensible Health Record Authentication Authentication of paper health records Signatures Initials Stamps

Authentication Issues Legal Aspects of Healthcare Maintaining a Legally Defensible Health Record Authentication Issues Issues related to all record types Auto-authentication Countersignatures Multiple staff authentication Accuracy and completeness is responsibility of the author Authorship is the origination and creation by a specific individual Abbreviations Legibility

Changes to the Health Record Revisions Corrections or alterations Legal Aspects of Healthcare Maintaining a Legally Defensible Health Record Changes to the Health Record Revisions Corrections or alterations Additions Late entries, amendments, addenda Deletions Version Management

View the original entry Enter the current date and time Legal Aspects of Healthcare Maintaining a Legally Defensible Health Record Actions to Perform When Correcting an Entry in a Computerized Health Record System View the original entry Enter the current date and time Identify the person making the change Note the reason for the change Verify that a hard copy printed from the EHR reflects the correction

Actions to Perform When Making an Addendum Legal Aspects of Healthcare Maintaining a Legally Defensible Health Record Actions to Perform When Making an Addendum Document the current date and time Write “addendum” and state the reason for the addendum, referring back to the original entry Identify any sources of information used to support the addendum Complete the addendum as soon after the original note as possible In an electronic system, provide a link to the original entry or insert a symbol by the original entry to indicate the existence of the addendum

Timeliness and Completeness Legal Aspects of Healthcare Maintaining a Legally Defensible Health Record Timeliness and Completeness Timeliness mandated by legal and accreditation standards Timeliness is important for evidence and admissibility Completeness Concurrent analysis Analysis at discharge

Health Record Identification Legal Aspects of Healthcare Maintaining a Legally Defensible Health Record Health Record Identification Ensuring correct identification Master Patient Index Unique identifier for each patient – Medical Record Number (MRN) Each patient visit creates account/billing number under MRN Problems in maintaining correct identification Duplicate medical record numbers (MRNs) Compromised MRN Overlayed data

Health Record Identification Legal Aspects of Healthcare Maintaining a Legally Defensible Health Record Health Record Identification Causes of errors in patient identification Wrong information from third parties EMS, PCP, Nursing homes Wrong information from patients Dementia, Deception, Forgetfulness, Lack of ID Registration/scheduling workflow issues Poor patient search techniques Lack of training Poor data definitions allowing poor data integrity, accuracy Human errors in data entry

Sources Legal Aspects textbook The Legal Health Record Legal Aspects of Healthcare Maintaining a Legally Defensible Health Record Sources Legal Aspects textbook The Legal Health Record