Case Studies in Health Information Mangement Second Edition Case 4-21 Our facili
ID: 92930 • Letter: C
Question
Case Studies in Health Information Mangement
Second Edition
Case 4-21
Our facility has a hybrid medical record. We implemented an EHR 6 months ago. We store paper records in hard copy for 2 years. We store microfilm for 50 years. We currently keep copies of records from other facilities in with our paper records. The radiology reports, lab reports, nurse’s notes, orders, dictated reports and pharmacy systems feed the EHR. Our physicians will not let us eliminate the hard copy record so we print out everything in the EHR and file it in the chart. We have received a subpoena for any and all records in a sensitive medical malpractice case. Since the case is so sensitive, we want to make doubly sure that we provide the appropriate documentation. The patient has been to the facility multiple times beginning 30 years ago with the most recent visit being 6 weeks ago.
Answer the following question about this case:
1. What is the legal health record for this patient?
2. How should the facility respond to the "any and all" statement?
Explanation / Answer
1.Legal health record is the documentation of health care services provided to individual during any type of health care .Document the services provided as legal testimony regarding the patient illness or any injury...