Legal Health Record Standards and Practices in Canada and the United States

Legal Health Record Standards and Practices in Canada and the United States

This comprehensive resource is designed for health information professionals navigating the complexities of defining, managing, and maintaining the Legal Health Record (LHR) within Canadian and U.S. healthcare systems. Developed by the CHIMA eLHR Working Group, this guide provides a framework for ensuring compliance with legal, regulatory, and professional standards.

Key features include:

1. Detailed steps for defining and updating the LHR.
2. Insights into the relationship between the LHR, the Designated Record Set (DRS), and Electronic Health Records (EHR).
3. Best practices for developing LHR policies.
4. Examples of documents included in the LHR and DRS.
5. Guidance on multidisciplinary collaboration for LHR implementation.

With this resource, healthcare organizations can enhance patient care, ensure operational efficiency, and mitigate risks in an increasingly digital healthcare environment.