Policy Level: Policy Title: Harborview Medical, rthwest Hospital & Medical,, UW Medical including Seattle Cancer Care Alliance, UW Neighborhood Clinics, Airlift rthwest and Hall Health UW Medicine Definition, Retention, and Disclosure of the Legal Medical Record Policy Number: Date Established: 8/1/2009 Date Revised: 7/12/2013, 03/05/2012, 08/01/2009 Date of Last Cyclic Review: 7/12/2013 Purpose The legal medical record (LMR) is the term used to identify what healthcare information constitutes the medical center s official business record. The LMR is the set of records typically used when responding to formal requests for information for legal and legally permissible purposes and also includes that which complies with accreditation and professional practice standards. The legal medical record (LMR) is the collection of information concerning the care provided to a patient that is created and maintained in the regular course of business, created by workforce members authorized to document in the patients record, who have knowledge of the acts, events, conditions, opinions or diagnoses relating to the patient, and made at or around the time indicated in the documentation. The LMR may contain information received from third parties. Policies and procedures governing the LMR are designed to produce an LMR that meets the standards of reliability necessary for patient care, business, legal and evidentiary purposes. The LMR may include records maintained in an electronic clinical system or the health information/document management system that integrates data from multiple sources, including paper and that captures data at the point of care, and supports caregiver decision making. Historically at the medical centers, there was a distinct paper medical record which contained all documents bound together with covers. Prior to electronic medical record systems, the paper bound record provided distinction and comprised the legal medical record. Portions of our electronic medical record are located in various electronic systems but come together in one or more repositories. UWM entities typically have a hybrid system that has transformed with electronic medical record components. Because of this it has become necessary to identify and define the components which 1
comprise the legal medical record. Each LMR will contain sufficient, accurate information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers. Definitions Business record: A record 1. Created and kept in the regular course of business; 2. Of an act, condition, or event; 3. Made at or near the time of the act, condition, or event 4. In a manner indicating trustworthiness or reliability.2 Hybrid medical record environment: When the legal medical record is created and managed in various formats (such as paper and electronic formats) rather than in one format. Legal medical record: The legal medical record (LMR) is generated at or for a healthcare organization as its business record and is the record that is released upon request. It does not affect the discoverability of other information held by the organization. The custodian of the LMR is health information management (HIM) in collaboration with information technology personnel. HIM professionals oversee the operational functions related to collecting, protecting, and preserving the LMR, while information technology manages the technical infrastructure of the electronic medical record. The LMR is a formally defined legal business record for a healthcare organization. The LMR is individually identifiable data in any medium, collected and used in documenting healthcare or health status. Source systems: The systems in which data was originally created. Primary source system: An information system that is part of the overall clinical information system in which documentation is most commonly first entered or generated. Source of legal medical record: The storage system where the legal medical or health record is held. Policy The UW Medicine (UWM) entities that create medical records (Harborview Medical, rthwest Hospital & Medical,, UW Medical, UW Neighborhood Clinics and our affiliate, Seattle Cancer Care Alliance) will 2
create and maintain patient medical records that, in addition to their primary intended purpose of clinical and patient care use, will also serve the business and legal needs of those entities. Medical records for patients over the age of 18 will be retained for a period of no less than ten years following the last provision of health-related services. Medical records for patients under the age of 18 will be retained for a period of no less than 10 years after the last provision of health-related services and 3 years after patient attains the age 18, in order to support patient care, research and to comply with licensing and regulatory requirements. Procedure A. Each UWM entity maintains a medical record for all patients, both inpatient and outpatient, who receive health care services. Medical records for patients over the age of 18 will be retained for a period of no less than ten years following the last provision of health-related services. Medical records for patients under the age of 18 will be retained for a period of no less than 10 years after the last provision of health-related services and 3 years after patient attains the age 18. Each entity shall maintain a document which outlines the components contained in the electronic medical record and is considered part of the legal medical record. These are the documents that are included in the disclosure of the legal medical record. The list of elements will be maintained by HIM and will change over time as the electronic medical record (EMR) develops. B. When a request for the complete medical record is received for evidentiary purposes, the elements in the approved list will be provided as the legal medical record, unless the requester directs a smaller set of records to be provided. For other requesters it is customary to provide a sub set of pertinent records. This is due to the extremely high number of pages that a medical record may contain, which are generally not needed unless the intention for the all-inclusive legal medical record is clearly delineated. Secondary Medical Information (SMI) It is recognized that each entity has other protected health information (PHI) that has traditionally not been kept as part of the medical record. It is protected with the same degree of confidentiality as the medical record. The retention of SMI may vary from that of the LMR. SMI is available for legal purposes and is produced upon a specific request for a specific type of information. There is no centralized list for this information so it is not possible to respond to a general request for all secondary medical information. Examples include: 1. Patient-identifiable Source Data that is not included in the LMR in the absence of an interpretation or summarization of the data, such as: a. Data from which interpretations and summaries are derived. b. Data maintained in a clinical department information system or database. c. Photographs for identification purposes only, audio of dictation, some tracings, some videos/pictures of a procedure. Some source data, such as audio of dictation, is not maintained once it has been converted to text. 2. Administrative data is not considered part of the LMR, such as: 3
a. Patient-identifiable data used for administrative, regulatory, healthcare operations and payment purposes (such as an admission list or patient schedule). b. Other examples of Administrative data include: correspondence concerning release of information, event history/audit trails, and data reviewed for quality or utilization management. 3. Derived Data is not considered part of the LMR, such as: a. Information aggregated or summarized from patient records. b. Accreditation and regulatory reports, data for research purposes, public health records, statistical reports, etc. c. Legal correspondence. 4. Under certain circumstances, research may be included in the medical record. See Attachments for a list of source systems. Attachments: List of Entity Specific Source Systems rthwest Hospital & Medical Harborview & UW Medical (includes Seattle Cancer Care Alliance) UW Neighborhood Clinics Hall Health Airlift rthwest Siemens/Soarian ehim Paper Cerner/ORCA Radiology RIS Epic Prelude Historical Paper Chartmaxx Paper Inventory of Source Systems - Secondary Medical Information Reference UWM Administrative Policy & Procedure-HIM Policy 1 Definition, Retention, and Disclosure of the Legal Medical Record UWM Entity Department Name System Name Interpretation/Summary available in EMR system? Harborview & UW Anesthesia Docusys Yes Medical UW Medical Cardiology Verisys Yes although images are Echocardiology (name?) kept in this system Yes although images are kept in this system 4
UW Medical /Seattle Cancer Care Alliance Harborview & UW Medical Harborview, UW Medical, rthwest Hospital & Seattle Cancer Care Alliance Digestive Disease/Gastroenterology EndoPro Yes although images are kept in this system Pathology PowerPath by Sunquest Yes Radiology PACS & RIS Orders & Images stored in RIS/PACS All Clinical Departments Paper records although there is a project to implement scanning of paper documentation into ORCA underway Yes are stored Radiation Oncology IMPAC/Mosaiq Yes UW Medical Pain Clinic @ Roosevelt System where images UW Medical /Seattle Cancer Care Alliance & Valley Medical UW Medical Transplant Surgery MAX Yes Harborview & UW OR McKesson Yes Medical UW Medical Infection Control TheraDoc Yes UW Medical Pediatrics Neodata Some notes copied Harborview Medical Cardiology Echocardiography MINDscape UW Medical Laboratory Flow cytometry Yes UW Medical Neurology EMG and NCS Yes UW Medical Pulmonary Pulmonary Function Yes Tests UW Medical Cardiology King of Hearts Harborview & UW Medical Radiology Outside imaging reports Viewable in PACS but not radiology tab UW Medical Cardiology ECG Preliminary ECGs not in ORCA Harborview, UW Medical, Valley Medical Lab Sunquest Yes Harborview Medical & UW Medical Ophthalmology Symphony, images only All Financial documentation pre Oct 2012 Birthcenter (pre Oct 2012) Fetal monitor strips and some notes Emergency Department (pre Oct 2012 Radiology Charge capture and dictation reports copy Billing of network accounts Clinic McKesson Star CPN/QS MedHost Midas Mysis Yes 5
rthwest Hospital & rthwest Hospital & Network pre Jul 2012 Birthcenter Fetal Monitor strips (post Oct 2012)-Valley Ambulatory Clinics (not all) OBIX Allscripts Roles and Responsibilities Process Owner: Sally Beahan Date: 07/16/2013 Medical Director: Chief Health System Officer: Thomas Staiger, MD Johnese Spisso Date: 07/16/2013 Date: 07/19/2013 References [1] RCW 70.41.190. [2] Chapter 5.45 RCW ( Uniform business records as evidence act ) and ER 803. [3] RCW 70.41.190. Approvals Johnese Spisso 7/19/2013 _ Policy Approved By Date 6