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 should include developed x-rays, relevant text messages and emails, selectively included printed information, and necessary photos of the patient's body. Each should comply with HIPAA standards and state laws, and be stored securely to protect patient privacy and ensure accurate, comprehensive patient care data.

Step-by-step explanation:

The legal health record for a small pediatric clinic should consider technological, legal, and financial aspects regarding data storage, including the protection of patient privacy and compliance with health laws such as HIPAA. For instance, when determining whether to include certain types of information:

• Developed x-rays must be included as they are part of the patient's medical history and essential for the diagnosis and treatment. Digital storage systems for radiographic images, like Picture Archiving and Communication Systems (PACS), are commonly used and should comply with HIPAA regulations ensuring confidentiality, integrity, and availability of the images.
• Regarding text messages and emails, only pertinent communications related to the patient's care should be stored within the health record system, considering that they may contain protected health information (PHI). Care must be taken to ensure that any electronic communication system used is secure and compliant with privacy laws.
• Printed information from external sources like WebMD should be evaluated for relevance to the patient's health before being included. If included, they should be scanned and stored electronically in the patient's health record.
• Photos of the patient's body, showing bruises, cuts, or rashes, are an important part of the medical record and should be included, being stored securely in the EHR system. This visual documentation assists in ongoing care and potential legal inquiries.

Each type of data should be stored securely, with access strictly controlled to maintain patient confidentiality and should comply with both HIPAA and state regulations, which may impact the cost and complexity of the data storage solutions used by the clinic.