Medical reords
Collection of data recorded when a patient seeks medical treatment; Legal documents
Purposes of medical records
- Required by licensing authorities to track, document, and maintain patient data
- Provide documentation of patient's continuing health care from birth to death
- Provide foundation for managing patient's health care
- Serve as legal documents in lawsuit
What are the 5 C's of documentation on patient's medical records?
Concise
Complete(and objective) - no opinions, only observable facts
Clear(legibly written)
Correct
Chronologically ordered
Corrections to written medical records
- Draw line through error so it is still legible
- Write or type info above or below line or in margin
- Note why correction was made
- Enter date and time and initials
- Have another person witness correction and add initials if possible
Corrections to Electronic Health records
- Do not change original record
- Add an addenum
Addendum
Significant change or addition to electronic health record
What does addendum contain?
Patient name, date of service, medical record number, original report identified, and date and time of correction
Ownership of medical records
- Owned by facility that created them
- Patient owns information they contain
Doctrine of professional discretion
Principle under which physician have the right not to release a record if it is in the best interest of patient; Being treated for mental or emotional conditions
Retention and storage of records
- Kept until specified statute of limitations, usually 2-7 years
- Most physicians retain records indefinitely as they affect future treatment
Routine Release of medical information
- Insurance claims
- Transfer to another physician- records must be photocopied
- Use in court of law- subpoena
Providing medical information for lawsuit
- Make sure name, phone number of attorney, and court docket number of case are listed
- Verify copy is same as original in every way
- Verify patient name was a patient of physician named
- Verify trial date/time on subpoena
- Notify physician that subpo
Confidentiality of Alcohol and Drug Abuse, Patient record
A federal statute that protects patients with histories of substance abused regarding the release information about treament
Authorization to release records
- Authorization should be in writing
- Should include patient name, address, DOB
- Patient or guardian signature
- Only info specifically requested should be released
- Patient may rescind(cancel) consent
Consent
Permission from a person, either expressed or implied, for something to be done by another
EX: examine patient, perform test that aid diagnosis, treat patient
Doctrine of informed consent
Outline in a state's medical practice acts
Doctrine of informed consent; Patient understands..
- Proposed modes of treatments
- Why treatment is necessary
- Risks involved with treatment
- Available alternatives to treatment
- Risk of alternatives
- Risks involved if treatment is refused
Who cannot give informed consent
- Minors: Person under age of majority; exceptions include (emancipated minors-living away from home and responsible for own support, married minors, mature minors)
- Mentally incompetent person
- Person speaking limited or no English
Informed Consent and HIV testing
- State public health law varies for HIV testing
- Permission from legal guardian required for infants and young children
- Married minors, emancipated minors, and minor parents MAY have the right to consent
Consent form for patient imaging
- Patient knows that imaging will be used to document care
- Ownership rights belong to facility but imaging can be viewed or copied
- Images will be securely stored for specified period of time
- Images will not be released to outside agency without writ
When is Consent unnecessary?
- Emergency situations
- Good Samaritan Acts
Good Samaritan Acts
State laws protects physicians and sometimes other health care practitioners and laypersons from charges of negligence or abandonment if they stop to help victim of an accident or other emergency
- Give care in good faith
- Act within scope of training an
Health information technology (HIT)
Application of info processing, involving in both computer hardware and software that deals with storage, retrieval, sharing, and use of health care info, data, and knowledge for communication an decision making
Health insurance portability and accountability act (HIPPA)
privacy of health info and mandates certain procedures and standards for electronic transmission and storage of health care info
Technological threats to confidentiality
- Electronic transmittal records
- Photocopiers
- Fax machines
- Computers (monitors, destroys records on hard drives when computer is sold or recycled)
- Printers