health care law and legislation week 5
Chapter 18
Medical Records
LEARNING OBJECTIVES
• Describe the contents of medical records. • Explain the ownership and who can access a
patient’s medical record. • Explain the importance of maintaining complete and
accurate records. • Describe the advantages and disadvantages of
computerized records. • Explain what is meant by the medical record
battleground. • Describe why the medical record is important in legal
proceedings.
Medical Record Means of Communication
• Documentation of a patient's
– Illness
– Symptoms
– Diagnosis
– Treatment
• Planning tool for patient care
• Document communication (e.g., progress notes)
Medical Record Means of Communication – II
• Protect legal interests of patient, org, & practitioner
• Provide database for use in statistical reporting
• Continuing education
• Research
• Provide info necessary for 3rd-party billing
Managing Information: IM Plan addresses
• Patient care information • Flow of information • Accuracy of information • Timeliness • Confidentiality • uniformity of data collection and definitions • third-party payer needs • disaster plans for the recovery of information • annual review of the plan • managing change
Medical Record – I Admission record
• Demographic Data
– Age
– Address
– Reason for admission, social security number
– Marital status
– Religion
– Health insurance
• Advance Directives
Medical Record – II History
• Chief complaint
• History of present illness
• Past medical history
• Allergies
• Current Medications
• Social history
• Family history
• Reproductive History
Medical Record – III Physical
• General appearance
• Vital signs
• Skin
• Lymph nodes
• HEENT
• Neck
• Thorax, Lungs
• Female & male breasts
• Cardiovascular
• Abdomen
• Genitalia
• Rectum
• Musculoskeletal
• Neurologic
• Assessments
– Problem list
Medical Record – V Physical
• Consent Forms
• Assessments
– Physician H & P
– Nursing,
– functional,
– nutritional
– social
• Pain management records
• Treatment plan
• Physicians’ orders
• Diagnostic reports
– laboratory
– imaging
• Consultation reports
Medical Record – VI
• Operative reports – Post Op Note – Surgery
• Anesthesia –Assessment –Administration
• Medication administration records
• Pain management records
• Progress notes – Nursing notes – Notations of other
disciplines • Patient education • Discharge planning
– social service notes & reports
– medication use instructions
– Physician follow-up
Ownership & Release of Medical Records
• Ownership organization or professional rendering treatment
Ownership & Release of Records
• Ownership
• Request by Patients
– Right to access
• Requests: 3rd Parties
– insurance carriers (for processing claims)
– medical research
– educators
– government agencies
Ownership & Release of Records: Privacy Exception
• Psychiatric records
• Criminal investigations
• Medicaid fraud
• Substance abuse records
Retention of Records Varies Among States
• In Illinois, the ILL. Supreme Ct. held that a private cause of action existed under X-ray retention act. The plaintiff stated claim under the act, which provides that hospitals must retain X-rays & other such photographs or films as part of their regularly maintained records for a period of 5 years.
– See text case: Rodgers v. St. Mary's Hosp. of Decatur
Electronic Records Advantages – I
• Retrieve demographic information & consultants' reports, as well as lab, radiology, & other test results
• Improve productivity & quality
• Reduce costs
• Support clinical research
Electronic Records Advantages – II
• Play an ever-increasing role in education
• Allow for interactive computer-assisted diagnosis & treatment
• Allow for computer-generated prescriptions
• Generate reminders for follow-up testing.
Electronic Records Advantages – III
• Assist in the decision-making process.
• Aid in standardizing treatment protocols.
• Assist in the identification of drug-drug & food-drug interactions.
• Used in telecommunications around the world, transporting picture graphics (e.g., computed tomography scans) between nations.
Computerized Medical Records Disadvantages
• Increased risk of lost confidentiality – unauthorized disclosure of information
• High-tech crime – increases in cyber crime
• products & services to combat cybercrime
– costs to protect networks & critical infrastructures from cyber-based threats.
Medical Record Battleground
• Tampering
• Angry recordings
– registering complaints by other caregivers & the org
• Rewriting & replacing notes
Text Cases
• Alteration of Records
• Objection to Record Notations
• Tampering with Record Entries
• Rewriting and Replacing Notes
• Fatal Handwriting Mix-Up
Confidential & Privileged Communication
• Breach of Physician-Patient Confidentiality
• Ordinary Business Documents
• Attorney-Client Privilege
HIPAA Privacy Provision – I
• Patients able to access their record & request correction of errors.
• Patients must be informed of how personal info will be used.
• Patient consent for release of info for marketing purposes required.
• Patients can ask insurers & providers to take reasonable steps to ensure their communications are confidential.
• Patients can file privacy-related complaints.
HIPAA Privacy Provision – II
• Health insurers or providers document their privacy procedures.
• Health insurers or providers designate a privacy officer & train their employees.
• Providers may use patient info without patient consent for – purposes of providing treatment – obtaining payment for services – performing non-treatment operational tasks of
the provider's business.
Charting & Helpful Advice - I
• Complete & pertinent entries
• Timely entries
• Legible entries
• Clear & meaningful entries
• Complete
Charting & Helpful Advice - II
• Avoid
– defensive & derogatory notes
– erasures & correction fluids
– criticism
– complaints
– tampering with the chart
Charting & Helpful Advice - III
• Secure records pending legal action
• Obtain legal advice
• Entries made by others must not be ignored.
– patient care is a collaborative interdisciplinary team effort.
– Entries made by health care professionals provide valuable information in treating the patient.
REVIEW QUESTIONS – I
1. What are basic purposes of medical record?
2. Discuss advantages & disadvantages of computer-generated medical records.
3. Medical record is sole property of the hospital & should never be released. Discuss your opinion on this statement.
4. How long should patient records be maintained?