1. 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

2. 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

3. 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

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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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