The director of health information management, as custodian of medical records, is having a great deal of difficulty responding to subpoenas for patient records. The facility is in the midst of converting from a paper-based to an electronic patient record. Some information is on paper, some information is scanned immediately following discharge, and some information resides within the computer system. The process of finding and identifying the various parts of the patient’s record from the various sources is time-consuming and there is concern about ensuring the same response (i.e., the legal medical record) is given each time the record is requested.

An attorney requested a record and then sent in an additional request. What was received from the facility the first time was substantially different from that which was received the second time. When the attorney deposed the custodian, many questions were raised about how record requests were handled, daily operational processes including how the patient’s legal medical record was compiled in response to this subpoena, and if this was the true and complete record for the patient.

Discuss the steps that the director should take to assure that responses to subpoenas consist of the same information (i.e., the legal health record). Also, what policies and/or procedures would you recommend be considered at this facility to ensure compliance in the midst of this conversion?