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?