What is a legal EMR?

The medical record is a health care organization’s most important business and legal record.

Legal requirements, well defined for maintaining paper medical records, are additionally complex for electronic records.

Medical records must be maintained in a way that is legally sound or they risk being challenged as invalid.

EMR selection criteria must include ensuring that a given EMR is appropriately designed and can be appropriately used to ensure adherence to federal and state rules, as well as institutional requirements and additional certification standards that may apply to their organization.

Why does the EMR need to be a legal record?

Simply, a health care organization must have a medical record. Its “medical record” must, by definition, meet all statutory, regulatory, and professional requirements for clinical purposes as well as for business purposes. If the record does not qualify as a legal record, it becomes hearsay and therefore is much less legally valid for business or for medical-legal purposes. Unless the practice intends to maintain separate paper records that comply with legal requirements, its EMR, to be a legal record, must conform to the same requirements as medical records in general and for business records on computers more specifically.

What if my EMR does not meet the requirements for a legal record? 

• As an invalid business record, a problematic EMR can be challenged by payors for billing or Pay for Performance (P4P).
• With an invalid medical-legal record, risk of adverse litigation outcomes and costs rise.

Information provided was obtained from Health Care Information and Management Systems Society.