Laws regarding promptly updating medical records
This process should be defined in HIM written policies and procedures and substantiates the authentication of an entry in a legal process.
If allowed by state, federal, and reimbursement regulations, electronic signatures are acceptable as authentication.
Examples of electronic disclosures include the creation of media such as electronic faxing, CD, DVD, PC-to-PC transmissions, and digital images.
Since federal and state laws will be challenged with the need to address the electronic disclosure of protected health information, routine assessment of acceptable alternative options to comply with such disclosures is recommended.
Generally, a statement and signature of the record custodian are sufficient; however, some states may require a witness or notary signature as well.
There are some simple steps you can take when responding to requests for EHRs for legal process: Having reviewed and established that the request is HIPAA compliant, determine if the information may be disclosed based on the context of the request received.
The Rules of Evidence indicate that the author of the entry is the only one who has knowledge of the entry.
It does not affect the discoverability of other information held by the organization.
The custodian must determine whether to release the record, what portions of the record should be released, and whether the record is admissible as evidence.
However, the custodian of an EHR has several additional concerns when an EHR is involved in litigation.
Electronic signature technology should provide verification of the identity of the author.
The certification process verifies that the copy provided is an exact duplicate of the original.