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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority as integrated effective July 1, 2015, including the legacy operations and staff of UWHC
Policy Title: UW Health Legal Medical Record
Policy Number: 6.39
Effective Date: January 1, 2016
Chapter: Medical Records
To define the elements that comprise the legal medical record (LMR) for UW Health.
Health Link - The UW Health electronic medical record (Epic)
Legal Medical Record (LMR) - The organization's official record that is released upon request for the
"medical record". It documents services provided to patients and may include additional documentation
relied upon by UW Health’s healthcare practitioners when making medical decisions.
Secondary Medical Information (SMI) - other protected health information (PHI) that has traditionally not
been kept as part of the legal medical record
A. Legal Medical Record (LMR)
1. Documentation that comprises the LMR may physically exist in separate and multiple
paper-based or electronic-based forms. The Health Information Management (HIM)
department will compile the elements and release the record.
2. The LMR excludes medical records that are not official records of UW Health even
though copies have been utilized by UW Health (such as outside records). The only
a. The LMR includes reports/results that were ordered at UW Health but were
b. The LMR includes a History and Physical done by an external physician that was
utilized as all or part of the history and physical for admission to or procedures at
c. The LMR includes data elements from outside sources that are embedded in UW
Health tables and documents, including partner affiliates.
3. The LMR does not include records in the Health Link system that are generated as part of
University of Wisconsin research unless the records of clinical treatment were provided
in UW Health facilities. Requests for UW research records must be directed to University
B. Secondary Medical Information (SMI)
SMI is protected with the same degree of confidentiality as the legal medical record. Document
retention schedules for SMI may vary from that of the legal medical record. SMI may be
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available for legal or other purposes and will be produced as required by law, or may be produced
as permitted by law, upon a specific request for a specific type of information. There is no
centralized list for this information so it is not possible to respond to a general request for all
secondary medical information. This is not a guarantee that records listed here will not be
released as part of the LMR; it is possible that some such records may inadvertently be released.
1. Patient-identifiable source data that is not included in the LMR (other than when directly
included in an interpretation or summarization of the data), such as:
a. Data from which interpretations and summaries are derived.
b. Data maintained in a clinical department information system or database.
c. Photographs, audio of dictation or other recordings, x-rays, diagnostic images,
tracings, videos. Some source data, such as audio of dictation, is not maintained
once it has been converted to text.
d. Signal tracings (EKG and other tracings) from which interpretations are derived.
e. Raw data from questionnaires.
2. Administrative data is not considered part of the LMR, such as:
a. Patient-identifiable data used for administrative, regulatory, healthcare operations
and payment purposes (such as an admission list, or patient schedule).
b. Other examples of Administrative data include: correspondence concerning
release of information, event history/audit trails, and data reviewed for quality or
3. Derived data is not considered part of the LMR, such as:
a. Information aggregated or summarized from patient records.
b. Accreditation and regulatory reports, data for research purposes, public health
records, statistical reports, etc.
c. Legal correspondence.
4. Personal health records (PHRs) that are patient controlled, managed, and populated, such
5. Outside records received from outside providers or other outside sources.
a. Excluding those listed in III.A.2.
6. Earlier versions of clinical documentation. The LMR will include only the most recent
version of each document.
A. UW Health maintains a "medical record" (which may include paper and electronic information)
for all patients, both inpatient and outpatient, who receive health care services at any UW Health
site. The "medical record" is what is defined to be the "Legal Medical Record."
B. The Director of HIM and General Counsel or their designee(s) shall approve what information
contained in the electronic healthcare record is considered part of the LMR and is included in the
release of an LMR. All information maintained in the paper/electronic medical record is
considered part of the LMR with the exception of those elements documented in the LMR
Exclusion List. The list of excluded elements will be maintained by HIM.
C. When a valid request for a complete/entire (certified) medical record is received, the entire LMR
will be provided. For all other requests, a smaller set of records may be provided, as requested.
Sr. Management Sponsor: SVP, Chief Information Officer
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Author: Director, Health Information Management
Approval Committee(s): Medical Record Committee; UW Health Administrative Policy & Procedure
President, University of Wisconsin Hospitals
Chief of Clinical Operations
Previous revision: 092014
Next revision: 012019