Medical Law and Ethics, Second EditionBonnie F. Fremgen

©2006 Pearson Education, Inc.Pearson Prentice HallUpper Saddle River, NJ 07458

The Medical Record

Chapter 9

Medical Law and Ethics, Second EditionBonnie F. Fremgen

©2006 Pearson Education, Inc.Pearson Prentice HallUpper Saddle River, NJ 07458

The Medical Record

All written documentation relating to patient Includes

– Past history– Current diagnosis and treatment– Correspondence relating to patient

Is a legal document May be subpoenaed

Medical Law and Ethics, Second EditionBonnie F. Fremgen

©2006 Pearson Education, Inc.Pearson Prentice HallUpper Saddle River, NJ 07458

Purpose of the Medical Record

Record of patient from birth to death

Document for continual management of patient’s health care

Provides data and statistics

Tracks ongoing patterns of patient’s health

Medical Law and Ethics, Second EditionBonnie F. Fremgen

©2006 Pearson Education, Inc.Pearson Prentice HallUpper Saddle River, NJ 07458

A medical records filing system Figure 9-1

Medical Law and Ethics, Second EditionBonnie F. Fremgen

©2006 Pearson Education, Inc.Pearson Prentice HallUpper Saddle River, NJ 07458

Contents of the Medical Record

Personal information about patient Clinical data or information

– Records of medical examinations– X-rays– Lab reports– Consent forms

Medical Law and Ethics, Second EditionBonnie F. Fremgen

©2006 Pearson Education, Inc.Pearson Prentice HallUpper Saddle River, NJ 07458

Two Common Forms of Charting

POMR: Problem-Oriented Medical Record includes chronological record of each visit

SOAP: subjective, objective, assessment, plan– Subjective statements of patient– Objective data such as lab reports, vital signs– Assessment or diagnosis– Plan of treatment

Medical Law and Ethics, Second EditionBonnie F. Fremgen

©2006 Pearson Education, Inc.Pearson Prentice HallUpper Saddle River, NJ 07458

Corrections and Alterations

Draw one line through error Write correction above error Date and initial change Do not erase or use correction fluid Falsification of medical record is grounds for

criminal indictment

Medical Law and Ethics, Second EditionBonnie F. Fremgen

©2006 Pearson Education, Inc.Pearson Prentice HallUpper Saddle River, NJ 07458

Timeliness of Documentation

Medical records must be accurate and timely

All entries must be made as care occurs or as soon as possible afterward

Should be completed within 30 days following patient's discharge from hospital

Medical Law and Ethics, Second EditionBonnie F. Fremgen

©2006 Pearson Education, Inc.Pearson Prentice HallUpper Saddle River, NJ 07458

Completeness of Entries

Medical records document type and amount of patient care that was given

In eyes of court, “if it’s not documented, it wasn’t done”

Medical Law and Ethics, Second EditionBonnie F. Fremgen

©2006 Pearson Education, Inc.Pearson Prentice HallUpper Saddle River, NJ 07458

Confidentiality

Medical records should not be released to third parties without patient’s written consent

Only specific records requested should be copied and sent

Taking photos or other visual images of patient without consent is invasion of patient’s privacy

Medical Law and Ethics, Second EditionBonnie F. Fremgen

©2006 Pearson Education, Inc.Pearson Prentice HallUpper Saddle River, NJ 07458

Ownership

Physicians or owners of health care facility own medical record

Patient’s have legal right of “privileged communication” and access to records

Patients must authorize release of records in writing Doctrine of professional discretion: physician may

determine, based on his or her best judgment, if patient with mental or emotional problems should view medical record

Medical Law and Ethics, Second EditionBonnie F. Fremgen

©2006 Pearson Education, Inc.Pearson Prentice HallUpper Saddle River, NJ 07458

Release of Information

Record may not be released to patient without physician’s permission

Patient must sign release form for information to be sent to insurance company

Never send entire medical chart unless it is requested

Medical Law and Ethics, Second EditionBonnie F. Fremgen

©2006 Pearson Education, Inc.Pearson Prentice HallUpper Saddle River, NJ 07458

Privacy Act of 1974

Agency may maintain only information relevant to its authorized purpose

Citizens have right to gain access to records and to copy records if necessary

Applies only to federal agencies and government contractors

Medical Law and Ethics, Second EditionBonnie F. Fremgen

©2006 Pearson Education, Inc.Pearson Prentice HallUpper Saddle River, NJ 07458

State Open Record Laws

Some states have freedom of information laws that grant public access to records maintained by state agencies

Medical records generally are exempt from this statute

Medical Law and Ethics, Second EditionBonnie F. Fremgen

©2006 Pearson Education, Inc.Pearson Prentice HallUpper Saddle River, NJ 07458

Alcohol and Drug Abuse Patient Records

Public Health Services Act protects patients who are receiving treatment for drug and alcohol abuse

Person or program that releases confidential information relating to these patients is subject to criminal fines

Exception if patient should require emergency care

Medical Law and Ethics, Second EditionBonnie F. Fremgen

©2006 Pearson Education, Inc.Pearson Prentice HallUpper Saddle River, NJ 07458

Retention and Storage of Medical Records

Each state varies on length of time records must be kept

Legally, records must be stored for a minimum of seven years from time of last entry

Minor’s records must be kept until patient reaches age of maturity plus period of the statute of limitations

Medical Law and Ethics, Second EditionBonnie F. Fremgen

©2006 Pearson Education, Inc.Pearson Prentice HallUpper Saddle River, NJ 07458

Storage

Current records usually kept within physician's office

May rent storage space

May be placed on microfilm

Medical Law and Ethics, Second EditionBonnie F. Fremgen

©2006 Pearson Education, Inc.Pearson Prentice HallUpper Saddle River, NJ 07458

Medical records storage unit Figure 9-2

Medical Law and Ethics, Second EditionBonnie F. Fremgen

©2006 Pearson Education, Inc.Pearson Prentice HallUpper Saddle River, NJ 07458

Computerized Medical Records

Data on patient records can be created, modified, authenticated, stored, and retrieved by computer

Special safety measures should be taken to establish personal identification and user verification codes for access to records

Should be accessed on need-to-know basis

Medical Law and Ethics, Second EditionBonnie F. Fremgen

©2006 Pearson Education, Inc.Pearson Prentice HallUpper Saddle River, NJ 07458

Reporting and Disclosure Requirements

State laws require disclosure of some confidential medical record information without patient’s consent

Reporting and disclosure are duties of the physician

Medical Law and Ethics, Second EditionBonnie F. Fremgen

©2006 Pearson Education, Inc.Pearson Prentice HallUpper Saddle River, NJ 07458

Duty to Report AIDS, HIV, and ARC Cases

All states require reporting of AIDS to local or state department of health

Most states require HIV and ARC cases be reported as well

Who reports cases varies by state Many states have confidentiality statutes that allow

notification of an HIV patient’s spouse, needle-sharing partner, or other contact person who is at risk of the infection

Medical Law and Ethics, Second EditionBonnie F. Fremgen

©2006 Pearson Education, Inc.Pearson Prentice HallUpper Saddle River, NJ 07458

Use of Medical Record in Court

Improper Disclosure: health care providers and institutions may face civil and criminal liability for releasing medical records without proper patient authorization

Subpoena Duces Tecum: written order requiring person to appear in court, give testimony, and bring information described in subpoena