Medical Records and the Law

The Movement to Electronic Health Records 441the documentation of healthcare services provided to an individualduring any aspect of healthcare delivery in any type of healthcareorganization. It is consumer- or patient-centric. The legalhealth record contains individually identifiable data, stored on anymedium, collected and directly used in documenting health status[emphasis added]. 4(See the more detailed discussion of the legal health record in Chapter3.) To demonstrate the impact of EHRs on health information managementfunctions, AHIMA has also prepared a detailed analysis ofeach function required to maintain a health record as that functionwould be performed for a paper health record, a hybrid paper-electronichealth record, and an EHR. 5 For example, for the function of abstractingdata elements, manual retrieval of information from a paper recordcould be eliminated in an EHR, if the application software automaticallycaptured information for data abstracts. The analysis shows howdramatically information management tasks will change as organizationsmigrate from paper to electronic record keeping.The Institute of Medicine has identified the following core functionalitiesof an EHR:• Health information and data about patients, including test results,medications, urgent developments, and medical and nursing diagnosisand care• Results management, allowing for readily accessible results, criticallinkages among multiple providers, and improved care coordination• Order entry/management, permitting provider order entry, improvedwork flow processes, increased clinician productivity, and reducedundetected errors• Decision support, so as to enhance clinical performance with computerassisteddiagnosis and disease treatment and management4American Health Information Management Association (AHIMA), Practice Brief: Update:Guidelines for Defining the Legal Health Record for Disclosure Purposes (Sept. 2005),64A; Practice Brief: Core Data Sets for the Physician Practice Electronic Health Record (Oct.2003), available at http://library.ahima.org/expdio/groups/public/documents/ahima/pub_ bok1_021607.html.5A. Tegan, et al., “The EHR’s Impact on HIM Functions,” Journal of AHIMA 76 (May2005).