The Medical Record

1. The Medical Record Chapter 9

2. 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

3. 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

4. A medical records filing systemFigure 9-1

5. Contents of the Medical Record • Personal information about patient • Clinical data or information • Records of medical examinations • X-rays • Lab reports • Consent forms

6. 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

7. 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

8. 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

9. 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”

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. Storage • Current records usually kept within physician's office • May rent storage space • May be placed on microfilm

18. Medical records storage unitFigure 9-2

19. 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

20. 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

21. 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

22. 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