The Legal EHR

With the movement towards electronic health record systems, there is an increasing need to authenticate and secure these records.  The accuracy of time stamping is a vital part in determining the origin, creation, and alteration of an EHR.

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Organizations such as HL7, CCHIT, and the IHE have taken steps in mandating the accuracy and source of time related to electronic health and medical records.

Many EHR software vendors provide the ability to timestamp records, but they do not provide an official time source for such actions.  In order to create a truly legal document, one must be able to prove the accuracy and validity of the timestamp.  As an EHR is looked at as a legal business document with an audit trail, an organization must be able to prove that the time associated with that document is official.

HIMSS Legal Electronic Medical Record Brochure

Time is an important element of medical record policies for legal considerations.

HIMSS web page for EMR brochures

HIMSS legal EMR brochure - pdf