ASET Position Statement
Retention of Neurodiagnostic Procedure Data
A legal health record (LHR) is the documentation of healthcare services provided to an individual during any aspect of healthcare delivery in any type of healthcare organization. It is consumer- or patient-centric. The LHR contains individually identifiable data which are stored on any medium and collected and directly used in documenting healthcare or health status.
The American Health Information Management Association (AHIMA) defines the LHR as "generated at or for a healthcare organization as its business record and is the record that would be released upon request. It does not affect the discoverability of other information held by the organization. The custodian of the LHR is the health information manager in collaboration with information technology personnel. Health Information Management (HIM) professionals oversee the operational functions related to collecting, protecting, and archiving the LHR, while information technology staff manages the technical infrastructure of the electronic health record." (AHIMA 2005).
Legal health records must meet accepted standards as defined by applicable Centers for Medicare and Medicaid Services’ Conditions of Participation, federal regulations, state laws, and standards of accrediting agencies, such as The Joint Commission, as well as the policies of the healthcare provider.
Law regarding minimum medical record retention periods is established by individual states.
Neurodiagnostic procedures and interpretation are part of the patient’s LHR. Electroencephalographic tracings, evoked potentials, and nerve conduction velocity waveforms should be stored on reliable, secured electronic media such as CD, DVD, or dedicated server. Long-term monitoring data that have been clipped according to the department-specific guidelines, as well as intraoperative neurophysiologic monitoring clipped data, are also stored in archived media that can be easily retrieved. For more information, please refer to the American Clinical Neurophysiology Society (ACNS) Guideline 4: Recording Clinical EEG on Digital Media (Neurodiagn J. Vol. 56, No. 4).
To comply with state regulations and requirements regarding Medical Records Retention, ASET strongly recommends that Neurodiagnostic services departments follow protocols and requirements set forth by their HIM professionals and the Information Technology departments at their individual facilities in their state.
American Health Information Management Association (AHIMA). The legal process and electronic health records. 2005. On the Internet at: http://library.ahima.org/doc?oid=59559#notes Accessed August 2013.
-- Approved by the ASET Board of Trustees July 29, 2013