Explain the purpose of medical records and the importance of correct documentation
Medical Records and Informed Consent
LEARNING OUTCOMES After studying this chapter, you should be able to:
LO 7. I Explain the purpose of medical records and the importance of correct documentation.
LO 7.2 Identify ownership of medical records and determine
how long a medical record must be kept by the owners.
LO 7.3 Describe the purpose of obtaining a patient ‘s consent for release of medical information, and explain the
doctrine of informed consent.
LO 7.4 Describe the necessity for electronic medical records and the efforts being made to record all medical records electronically.
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LO 7.1 Explain the purpose of medical records and the importance of correct documentation.
medical record A collection of data recorded when a patient seeks medical treatment .
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FROM THE PERSPECTIVE OF . .. –
SALLY, MICHAEL, AND TERESA handle requests for release of patients’ medical records for a midwestern hospital serving a five-state area. They emphasize that they can release records only with signed authorization from the patient or on subpoena, and that they may then release photocopies, but never original medical records. When some- one visits the hospital to pick up copies of a patient’s records, that per- son is asked to show identification.
Michael lets experience be his guide and checks out any request for release of records that “doesn’t feel right.” For example, if a hus- band brings an authorization form for release of medical records that he says his wife signed, her signature should be checked against the signature on hospital admission forms. It could be that a divorce is in progress in such a situation, and the husband or wife is seeking medi- cal records to prove the spouse an unfit parent.
“Never release medical records because the person making the request has intimidated you,” adds Teresa. “The most officious person I’ve dealt with was an FBI agent who told me, ‘I want this record. If you don’t give it to me, I’ll get it myself.’ I said, ‘Go for it.’ Later the agent called and apologized to me.”
Since the employing hospital is located in a city with an air force base, Sally, Michael, and Teresa often receive requests for medical records for active duty military personnel. “We have now been told that the mili- tary can get the records they request on any active duty person,” adds Sally. “We still ask for an authorization, but it is not required, since the active duty person signs away that right when he or she signs up for the military. This applies to active duty personnel on duty or on leave, but it does not include dependents of the person in the military.”
Michael, Teresa, and Sally know that medical records contain informa- tion that can be used in ways not intended when the health care data were collected. They also know that the hospital that employs them can be legally liable for improper release of medical records. Therefore, they are extremely careful about always obtaining proper consent before releasing records.
From the perspective of individuals seeking medical records for their own purposes, not related to health care or the welfare of patients, Michael, Teresa, and Sally are unrelenting obstacles. From the perspective of the patients whose confidential medical records are conscientiously protected, Michael, Teresa, and Sally are performing their jobs well. From the perspec- tive of their employer, Michael, Teresa and Sally are performing their jobs well and following the laws pertaining to the release of medical records.
Medical Records A medical record is a collection of data recorded when a patient seeks medical treatment. The medical record, as used in this chapter, refers to a patient’s visits to one health care facility. The health record cov- ers all of a patient’s health care issues, and covers all health care facili- ties the patient may have visited. The two terms are discussed in further detail in Chapter 8. Hospitals, surgical centers, clinics, physician
176 Part Two J Legal Issues for Working Health Care Prac titioners
offices, and other facilities providing health care services maintain patients’ medical records. Medical records serve many purposes:
1. They are required by licensing authorities and provide a format for tracking, documenting, and maintaining a patient’s communi- cation data, both inside and outside a health care facility.
2. They provide documentation of a patient’s continuing health care, from birth to death.
3. They provide a foundation for managing a patient’s health care.
4. They serve as legal documents in lawsuits.
5. They provide clinical data for education, research, statistical tracking, and assessing the quality of health care.
ENTRIES
As a legal document, a patient’s medical record may be subpoenaed (via subpoena duces tecum) as evidence in court. When they are conscien- tiously compiled, medical records can prevail over a patient’s recollection of events during a trial. When there is no entry in the record to the effect that something was done, there is a presumption that it was not done, and when there is an entry that something was done, the presumption is that it was done. Therefore, what is omitted from the record may be as important to the outcome of a lawsuit as what is included.