Healthcare Information Technology Exam Guide for CompTIA Healthcare IT Technician and HIT Pro Certifications

The Role and Use of the Medical Record in Litigation

As previously discussed, one of the important secondary uses of the medical record is to provide support and documentation for legal matters. Irrespective of its form (paper or electronic) or location, the patient’s medical record also serves as an important form of evidence that is often used in the litigation process. Yet the process by which medical records are discovered and admitted into evidence is evolving as rapidly as our nation’s health information infrastructure. Vast and significant differences exist between the role and use of paper versus electronic health records (EHR) as evidence in a court a law. The remainder of this chapter will focus on the legal process of discovery and ...