Title: Electronic Health Records
Course: HIM 2012 Health Law > Section: Module 6 - Electronic Health Records

Introduction

The rapid movement from paper health records to electronic health records (EHRs) is purposed to promote better patient care and reducing healthcare costs.  Health information professionals have the challenge of managing confidentiality, privacy, and security of health patient health records in the electronic environment.   In addition, federal laws, state laws and accrediting agencies affect the creation, and use of patient health records.

The HIM professional must be responsible for defining the legal health record whether in electronic or paper format, or both.  There must be policies and procedures that relate to the definition, identify the content, maintenance of  documentation required to support  a legally sound patient health record based on relevant laws and organization needs.  The health record is central to any health care organization.

Objectives

Upon completion of this module, the student will be able to
- List the multiple purposes of the health record
- Explain the differences between the legal health record and the electronic health record
- Identify the documentation principles that support a legally sound health record
- Distinguish the maintenance and retention considerations for paper health record from those for electronic health records
- Describe the importance of establishing sound policies and procedures to support and manage health records

Readings & Resources

Required reading:  Brodnik, Melanie.  Fundamentals of Law for Health Informatics and Information Management.  AHIMA Press.  Current edition. (Chapter 8, Chapter 9)

Optional:  Pozgar, George.  Legal Aspects of Health Care Administration.  Jones and Bartlett Learning.  Current edition.  (Chapter 11)
Optional:  Roach, W.  Medical Records and the Law.  Jones & Bartlett Publishers.  Current edition.
Optional:  Servais, C.  The Legal Health Record.  AHIMA Press. Current edition
American Society of Law, Medicine and Ethics
American Health Information Management Association
Agency for Healthcare Research and Quality
Healthcare Information and Management Systems Society
American Medical Informatics Association
Health Level Seven International
HL7 Electronic Health Record

Assignments and Activities

- Read Chp. 8 and Chp. 9 in the Brodnik text

- Take the Module 6 Quiz
- Post on the Module 6 Discussion Board
- Post the Module 6 Internet Activity
- Continue working on the Health Law Electronic Portfolio (due in Module 10)