Question

identify what information you believe should be included in the legal health record of a small pediatric clinic. Specifically, I want you to comment on why or why not the following information should be included. Your discussions should include technological, legal, and financial issues involved with the data storage of each type of data. I would like you to include in your discussion where and in what form each piece of data would be stored.  

1. Developed x-rays
2. Text messages
3. Emails
4. Printed information that the patient may have brought in (e.g. printouts from WebMD)
5. Photos of the patient's body (e.g. bruises, cuts, rashes, etc.)

Answer 1

A legal health record (LHR) is the documentation of patient health information that is created by a health care organization.

1.Developed X rays:It can be used as legal health records as it gives information on patients condition and one of the diagnostic measures used in health care.So it can be used for getting information about patient condition and can be used as evidence to prove the health issues in legal matters.

2.Text messages:It should not be used because of privacy concern.As a result of the insecure nature of mobile phones, text messaging raises significant privacy and security concerns. Text messaging does not comply with the security regulations under the Health Information Portability and Accountability Act (HIPAA).If a device is lost, stolen, or recycled, patient information contained within the text messages is compromised. SMS text messages are often encrypted by the service provider, but this encryption used to protect text messages has weaknesses and can be broken and is not strong enough for the protection of sensitive health information.

3.Emails:it should not be used as there is privacy concern.t’s difficult to ensure the security of the email once it leaves the organization’s server. So sometimes personal information can be leaked by getting into the email address.

4.Printed information patient brought: it should not be used, as it gives common information regarding condition .Means it wont give the information about what patient is having it only gives common information of the condition which is for learning purpose like information from webmed.so it doest have exact information on the particular patient.For example patient brought information regarding appendicities from website saying he has right abdominal pain so he suspect he has appendicities seeing the infornation from net.But may be he diagnosed with other condition like cancer which is the cause of his pain.so the information he brought cannot be used as legal information of his as it is not his medial information.

5.Photos of patient's body:It can be used as legal health record as it gives information regarding hiscondition which can be used as medical evidence.For example ,If a patient has burns ,this image can be used in legal records to show his evidence of injurity.