Medical Records
Medical RecordMeans of Communication• Documentation of a patient's
– Illness– Symptoms– Diagnosis– Treatment
• Planning tool for patient care• Document communication (e.g., progress notes)
Medical RecordMeans 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 DirectivesMedical 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 listMedical 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 reportsMedical 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 RecordsAdvantages – I• Retrieve demographic information & consultants' reports, as well as lab, radiology, &
other test results• Improve productivity & quality• Reduce costs• Support clinical research
Electronic RecordsAdvantages – 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 RecordsAdvantages – 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.
- Medical Records
