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 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 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.