Summary: Legal Medical Record Standards Policy No. 9420
LEGAL MEDICAL RECORD STANDARDS
To establish guidelines for the contents, maintenance, and confidentiality of patient Medical
Records that meet the requirements set forth in federal and State laws and regulations, and to
define the portion of an individual's healthcare information, whether in paper or electronic
format, that comprises the medical record. Patient medical information is contained within
multiple electronic records systems in combination with financial and other types of data. This
policy defines requirements for those components of information that comprise a patient's
complete "Legal Medical Record."
Medical Record: The collection of information concerning a patient and his or her health care
that is created and maintained in the regular course of UC__ business in accordance with UC__
policies, made by a person who has knowledge of the acts, events, opinions or diagnoses relating
to the patient, and made at or around the time indicated in the documentation.
The medical record may include records maintained in an electronic medical / record
system, e.g., an electronic system framework that integrates data from multiple sources,
captures data at the point of care, and supports caregiver decision making.
The medical record excludes health records that are not official business records of UC,
such as personal health records managed by the patient.