Subpoenaed
a medical record ordered by the court to be available during a malpractice case
Medical record management requires
accuracy, confidentiality, and proper filing and storage
The purpose of a medical record is to
provide the medical picture and record of the patient from birth to death and provide data and statistics on health matters
Patient information in the medical record should include
the date of birth
The medical record must include information about patient care such as
admitting diagnosis, physician examination report and documentation of complications, discharge summary and follow up care
The disadvantage of chronological documentation is
medical problems may go undiscovered
The accepted method of correcting medical record errors is
draw a line through the error and write the correction above with the date and initials of the person making the correction
Federal reimbursement guidelines require that all medical records be completed within
30 days following the patients discharge from the hospital
An incomplete medical record may
make it impossible for the healthcare provider to defend allegations in court
For the courts purpose, if documentation does not appear in the medical record if
it did not occur
To protect patient confidentiality medical records can be released
only with the patients written consent
Ownership of the medical record usually remains with the
physician
When preparing a copy of a medical record for a third party
keep the original and send the copy
The privacy act of 1974 protects private citizens from distribution of information about themselves by the federal government except for that which is received from
veterans administration hospitals
Medical records are usually exempt from state open-record laws except when
the benefit of disclosure for the public safety overweight confidentiality
All medical records should be stored for
10 years from the date of last entry
Older records of former patients
can be stored in a clean, dry storage space
Computerized medical records
pose problems of confidentially, make record maintenance and retrieval more efficient and should be accessed on a need to know basis
Confidential medical record information that can be disclosed to a health department without the patients consent includes
HIV cases and AIDS cases
Physicians who wish to disclose confidential medical record information should
discuss it with the patient first
Laws regarding medical records
vary from state to state
Healthcare providers and healthcare institutions who disclose confidential health information may
face civil or criminal liability for disclosure
Immunization records should be kept
PERMANENTLY
A written order requiring a person to appear in court, give testimony, and bring the records described is called
subpoena duces tecum
A subpoenaed medical record should alert the medical staff that
the physician and the patient are to be told that a subpoena has been served
the physicians attorney should be notified of the subpoena being received
the records must be turned over to the judge on the specified date