In defining a legal health record, what should an HIM professional initially develop?

In defining a legal health record, it is essential for an HIM professional to start with a list of statutes and regulations. This foundational step is crucial because the legal health record must comply with various legal requirements and regulations that govern health information management, including federal, state, and local laws. These statutes and regulations dictate what constitutes a legal record, including what data must be included, how it should be stored, accessed, and shared.

Understanding and referencing these legal frameworks ensures that the records maintained are not only accurate and comprehensive but also uphold the privacy and security of patient information as required by law. This compliance helps organizations mitigate legal risks and prepare for any potential audits or legal inquiries.

The other options, while important aspects of health information management, come later in the process. For example, creating a list of data elements within records is important but should be informed by the legal requirements established from the statutes and regulations. Similarly, quality checks on health record systems and listings of information requests are operational considerations that follow the initial legislative framework needed to define a legal health record.