Learn About Valley’s New Legal Medical Record Policy

Valley Medical Center has a new policy that defines and outlines the use of patients’ Legal Medical Record. This policy is owned by Health Information Management and contains important information about how we handle records:

• The Legal Medical Record (LMR) is the official record used for clinical care, legal purposes, and billing.
• The Designated Record Set (DRS) is broader and may include additional information not considered part of the legal record.
• Not all communications or data (e.g., internal messages, administrative or quality-review content) are part of the LMR.
• Accurate, timely, and authenticated documentation remains essential and must support patient care and medical necessity.
• Do not alter original entries to the LMR. Use appropriate addendums or amendments when corrections are needed.
• Patient access rights apply, and documentation should remain clear, objective, and professional.
• Confidentiality and appropriate access to patient information are required at all times.

The full policy also includes definitions of what is and isn’t included in a patient’s LMR, how this information can be released and to whom, and how long Valley retains records. You can read the entire policy here.