AHIMA Releases Guidelines for Defining the Legal Health Record

Vol. 15 •Issue 19 • Page 13
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AHIMA Releases Guidelines for Defining the Legal Health Record

Regardless of a health record’s format—paper, hybrid or fully electronic—health care organizations must ensure that it meets the requirements of a legal health record, according to the American Health Information Management Association (AHIMA). AHIMA recently released its guidelines for defining the legal health record.

According to the AHIMA electronic health information management (e-HIM®) workgroup that developed the guidelines to assist organizations in defining their health record for legal applications, the definition of the legal health record must be continuously reassessed in light of new technologies, users and uses. With the advent of various electronic media, the Internet and the consumer’s enhanced role in compiling their health information, the definition of the legal health record has become more complex.

The work group also suggests that each organization define the content of the legal health record to best fit its system capabilities and legal environment. Considerations for the content of the legal health record should include ease of access to different components of patient care information, guidance from the medical staff and the organization’s legal counsel, community standards of care, federal regulations, state law and regulations, standards of accrediting agencies and the requirements of third-party payers.

For a copy of the workgroup’s complete report, “Guidelines for Defining the Legal Health Record for Disclosure Purposes,” visit AHIMA’s Web site at http://www.library.ahima.org/xpedio/groups/public/documents/ahima/pub_bok1_027921.html.

The e-HIM work group consisted of AHIMA members from various provider settings, law practices, information technology vendors and information systems consultants. AHIMA provides its industry-leading e-HIM education and advocacy programs to support the effective use of information technology to manage patient information and health care data. The workgroup was funded by a grant to the Foundation of Research and Education (FORE) from Precyse Solutions.

Clinical Vocabulary Mapping Methods Institute Announced

The Clinical Vocabulary Mapping Methods Institute has been added to the 2005 AHIMA Annual Convention and Exhibit lineup. Join AHIMA and a panel of national and international experts to explore mapping, the next frontier in clinical vocabularies. Maps are created between different clinical vocabularies and classification systems to enable “enter once, use many” functionalities in the EHR.

Two authoritative tracks have been planed on this. The first involves organizational issues (great for administration and leaders), and the second will focus on technical topics (great information for information technology staff and implementers). The cost of the full day institute is $160 for AHIMA members or $192 for nonmembers.

Speakers include:

• Betsy Humphreys, deputy director of the National Library of Medicine (invited).

• Simon Cohn, MD, associate executive director, The Permanente Federation, and chair, National Committee on Vital and Health Statistics.

• Jim Campbell, MD, University of Nebraska; SNOMED Editorial Panel; chair, SNOMED Mapping Workgroup

• Robert H. Dolin, MD, Kaiser Permanente

• Andy Kanter, president and chief medical officer, Intelligent Medical Objects

• Susan Matney and Cessily Johnson, Intermountain Health Care

• Susan Fenton and the AHIMA staff involved in the NLM SNOMED: ICD-9-CM Map Validation Project

As the EHR is on the horizon, attendees will learn what their organization needs to know—whether they’re just starting out or are further along—for successful implementation, and what they will encounter regarding clinical vocabulary maps. For more information, visit AHIMA’s Web site at www.ahima.org/convention/2005.

HI&T Week Planning Kit Available Now

Mark your calendars for National Health Information and Technology (HI&T) Week, Nov. 6Ð12, 2005, sponsored by AHIMA and the Canadian Health Information Management Association (CHIMA). The annual event was started 16 years ago to recognize the work of HIM professionals who maintain and protect the health information of individuals nationwide. The theme of this year’s celebration is “Information for a Healthy Nation,” and AHIMA has prepared a kit to help you plan your week. To access the planning kit online, visit www.ahima.org/hitweek.

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