Legal health record case study

The director of health information management, as the custodian of medical records, is having a great deal of difficulty responding to subpoenas for patient records. The facility is in the midst of converting from a paper-based to an electronic patient record. Some information is on paper (such as consents), some information is scanned immediately following discharge (such as nurses’ notes), some information is automatically (COLD) fed into the EHR system (such as transcription reports) and some information resides only within electronic systems (such as lab results and physician orders). The process of finding and identifying the various parts of the patient’s record from the various sources is time-consuming and there is concern about ensuring the same response (that is, that the legal health record is produced) each time a record is requested. An attorney requested a record, followed by an additional request. What he received from the organization the first time was substantially different from what he received the second time. When the attorney deposed the custodian, many questions were raised about how record requests were handled, daily operational processes including how the patient’s legal health record was compiled in response to this subpoena, and if this was the true and complete record for the patient.

What steps should the director take to ensure that responses to subpoenas consistently result in the true and complete health record of a patient?

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