A legal health record (LHR) is the documentation of patient health information that is created by a health care organization. The LHR is used within the organization as a business record and made available upon request from patients or legal services.
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There is no specific set of regulations for legal health records; however, they must meet standards set by federal and state laws. After meeting these basic standards, it is up to the discretion of the individual healthcare organization to decide what is and is not appropriate to reveal.
Historically, the legal health record was simply the contents of a paper chart but because more healthcare facilities are adopting electronic health records (EHR), using health apps for patient monitoring and tracking data on various forms of electronic media, defining and creating a legal health record is becoming increasingly complex.