Medical Ethics and Law: Chapter 9: The Medical Record
______ send the original version of the medical record to the patient.
Never - Make a copy and send it. X-ray Films may be released with approval from physician with stipulation they will be returned.
Under 1974 law, agency may maintain ____ information that is relevant to its authorized purpose
Only
State freedom of information laws that grant public access to records maintained by state agencies
Open-Record Laws
Medical record should never contain ______ material not related to patient or patient care.
irrelevant example: arguments between staff about patient's care.
All records removed from files should be listed in a:
journal with person given to and date along with placing an ID to show removed
Sometimes necessary for confidential information to be shared without ______ or _______ of person
knowledge or consent
Late entries into a medical record could equal:
lapse of memory about what actually occurred.
Medical record is a ______ record.
legal
Because medical record is legal document and contains an objective and factual record of a patient's medical condition and treatment, either patient or physician can use in _______ ________.
malpractice suit
With the use of EMR, an increase in concerns about patient privacy because:
many healthcare professionals now able to view a patients record unless precautions taken
Older records of former patients:
may be warehoused
The medical record serves as an important path for communication between_____ ______.
medical personnel
Each state varies on the length of time _____ ______ and _____ must be kept. Also whether it is the record of a minor or adult
medical records and documents
A physician can track the ongoing patterns of the patients health through ____ ______.
medical records.
Medical Records serve:
multiple purposes
Credible is defined as:
must be believable or worthy of belief, trustworthy and reliable
No personnel may sign any _____ other than their own.
name
Computerized health records should be accessed on a:
need to know basis
Need to know means
no healthcare worker should know any more personal information about a patient than necessary to meet his or her needs
Privacy act _____ applies to federal agencies and government contractors
only
Some states have freedom of information law called:
open-record laws
With well designed computerized systems, you will have tools to prevent unauthorized use such as:
passwords, encryptions, firewalls, personal identification and user verification codes, encoding before sending
A register of birth must be retained:
permanently
Most physicians store medical records ________ because malpractice suits can still be filed within two years from the date that the occurrence or alleged malpractice event became known.
permanently
Register of birth, death, surgical procedure, immunization records, and chemotherapy records are kept
permanently
All needed revisions needed to an electronic medical record should be brought to ______ attention.
physician. - Anytime record is examined the word revision will show up.
The Privacy Act of 1974 provides:
private citizens some control over information that the federal government collect about them
The Public Health Services Act:
protect patients who are receiving treatment for drug and alcohol abuse
Open-Record laws grant:
public access to records maintained by state agencies -- Medical records generally exempt from this statute ---If private patients interest in confidentiality is outweighed by the benefit of disclosure for public interest, then disclosure is allowed.
The purpose of issuing a subpoena for patient's medical record is to:
receive written evidence of the patient's medical condition and the care that was received.
Legal confidentiality obligations apply to all methods of _______ keeping.
record
Because the patient does have a legal right to his or her medical record, it is never acceptable to ____ to turn over a copy if the patient has not paid his or her bill
refuse
Patients must sign a ____ form when they request to have their medical records and films sent to another physician
release
Healthcare professionals and institutions such as hospitals, clinics, may face civil and criminal liability for:
release of medical record without proper patient consent
One person should be designated to maintain list of records:
removed and returned.
Various laws cover the _____, _____, and ____of medical records.
reporting, disclosure, and confidentiality
Patient has right to expect accurate medical records will be maintained and recorded in a ____ _____.
safe manner
Microfiche is an excellent way to:
safeguard and back up records. Plus a copy of the microfiche can be made and store in fire proof area
Almost impossible to hide a change in a medical records such as handwriting, type of ink, and paper can all be detected through _____ _______.
scientific testing
Billing information often maintained in a _________ accounting record.
separate
Records ____ _____ be released to the patient without the physicians knowledge and permission because information contained in the record could be upsetting if not explained first
should not
All healthcare personnel who provide care must document that care or treatment and _____ their name to documentation.
sign
The user should ______ all electronic records when not in use.
sign-off
Because of importance of medical record, some _____ have passed statutes that define what must be contained in the record.
states
Often its needed for another healthcare provider or consulting physician to review a medical record. Once need no longer exist, the right to review medical record ____.
stops
Proper management of medical records because they could be ______ during malpractice case.
subpoenaed
In most states, the general rule for ownership of medical records is that:
the physician owns them
Medical records should not be released to ___ ____ without patient consent.
third parties
Any entry made into a medical record after a lawsuit is:
threatened or filed is suspect.
State law require disclosure of some confidential patient information ______ patient consent.
without
Subpoena Duces Tecum:
written order requiring a person to appear in court, give testimony and bring particular records, files, books, or information that is described in subpoena
Falsification of medical records is grounds for:
indictment
Clinical data maintained in the medical record includes:
- All records and medical exams, x-rays, labs, and consent forms - Correspondence between patient and physician such as letters of withdrawal and consultation reports from physician - If patient has provided informed consent for a procedure or test that has been explained to him/her, then a record of this explanation and oral consent must be documented in medical record.
Medical record is valuable in ambulatory health care or hospital setting because:
- Base for management of patient's care - Alerts the physician and staff to patterns and changes in a patient's response - Provides data for research and education
Document patient comments such as "I'm all alone or I just feel I can't go on"....Why?
- Comments should be related to doctor-- indicate emotional problems in addition to physical one
Medical record is the most important document in a malpractice suit:
- Documents type and amount of patient care given - If incomplete, physician or other healthcare provider may be unable to defend allegations of malpractice, even if no negligence
Under the Privacy Act individuals were given right to:
- Find out what information is collected about them by government - See and have a copy of the information - Correct and amend their information - Exercise control over disclosure of that information
Before accepting subpoena check for:
- Name of attorney - Court case number - Physician named on subpoena
For subpoena medical records ensure you follow guidance:
- Only provide parts of record requested in subpoena - Unless original document is subpoenaed, a certified photocopy may be sent - If original is subpoena, a photocopy is marked copy and placed in file and mark where original record is at. Place receipt for subpoena record in file - patient or the patient's attorney should be notified that the record has been subpoenaed - Any notice relating to subpoenaed records should be sent to the patient by certified mail
Exception rule for consent to release records:
- Parents of minor children - Legal guardian - An agent (someone the patient selects) to act on their behalf in a Health Care Power of Attorney - Emancipated minor - minor and not the parent must sign the release
The medical record is all of the written documentation relating to a patient which includes:
- Past history information - Current diagnosis and treatment - Correspondence relating to patient
Contents of the medical record includes:
- Personal information about patient - Medical and Clinical notations supplied by the physician and other healthcare professionals caring for the patient
No photos, videos, or visual images of patients can be used without?
- Proper consent from patient - Patient must sign consent in order for photos or films to be used outside of medical facility - Without the proper consent, it's considered invasion of privacy
Purpose of Medical Record:
- Provide medical picture and record of the patient from birth to death - Important document for the continual management of a patient's healthcare - Furnishes documentary evidence of the course of evaluation and treatment - Assist physician in diagnosing, treating, and tracking the patterns of patient's health - Provides data and statistics on health matters such as births, deaths and communicable diseases
How do you treat an addendum or revision to an electronic medical record:
- RN or CMA can draft revision to medical record - Add revision and their name - Physician or authorized person to permanently add or change record - Physician will go into program and approve it and sign it to become permanent part of record.
Credibility Gap is defined as:
- apparent disparity between what is said or written and the actual facts - this gap results in a failure to accept one's statement as factual, or a person's professed motives as the true ones
Records should be kept in:
- clean, dry place for storage - must be available for court if needed - Some hire service to place on microfiche which results in space saving
Using EMR many benefits such as:
- data and patient records can be created, modified, authenticated, stored, and retrieved by the computer
If physician cannot retain records beyond 10 year time, then certain considerations for methods of destruction should be made:
- maintain careful records to when destroyed - assign POC for deciding based on policy, what records to keep and what to purge - define which records are kept onsite and which offsite - maintain log that details records on what has been destroyed, as well as when and how - provide method of disposal = shred - If by service company, then they must abide by HIPAA
Privacy Act of 1974 allows federal agencies to collect, maintain, use, or disseminate any record of identifiable personal information but only in a manner that assures that:
- such action is for a necessary and lawful purpose - the information is current and accurate for its intended use - adequate safeguards are provided to prevent misuse of such information - The information is used only in those cases where there is an important public policy need that has been determined by a specific statutory authority
The format of the medical record:
. Reflects the physician's specialty
Legally, how long should all medical records be stored from the time of the last entry?
10 years
Fetal heart monitor records are kept for
10 years after infant reaches maturity
Adult patient records are kept for
10 years after most recent encounter
Federal reimbursement guidelines mandate all medical records should be completed within ____ days following a patient's discharge from the hospital.
30
Federal reimbursement guidelines mandate that all medical records be completed within how many days following the patient's discharge from the hospital?
30 days
Medicare/Medicaid records should be kept for
5 years
Who is authorized to accept subpoena in healthcare facility?
A conservator of the record, such as medical records administrator, authorized to accept a subpoena on behalf of healthcare facility or physician
Use only ____ or _____ ink when charting a medical records. NEVER use pencil or colored ink pens
Black or Blue
As a legal document, the medical record can be used by
Both the defendant and the plaintiff...
The personal information in the medical record includes:
full name, address, telephone number, date of birth, marital status, employer, and insurance information
Open records law:
grant public access to records maintained by state agencies
Under _____ ____ _____ ______, a physician may determine based on judgment best if patient with mental and emotional problems should view record.
Doctrine of Professional Discretion
An apparent disparity between what is said or written and the actual facts
Credibility Gap
Believable or worthy of belief
Credible
Means that a physician may determine, based on his or her best judgment, if a patient with mental or emotional problems should view the medical record
Doctrine of professional discretion
Made known
Disclosed
Fully computerized method of record keeping
Electronic Medical Record
Scrambling and encoding information before sending it electronically
Encryptions
Software to prevent unauthorized users
Firewalls
______ operated by federal government are bound by the act to make their records available for public disclosure
Hospitals
You should not enter flippant or unprofessional comments into a medical record because:
It could be read by the patient and such comments would hurt his or her feelings
Who serves a subpoena?
Local sheriff or federal marshal. Some states allow age over 18
All the written and computer generated documentation relating to a patient
Medical Record
Miniaturized photographs of records
Microfiche
Under Medicare requirements, which items is NOT required in a medical chart?
Names of all the patient's children
_______ use unprofessional comments in a medical record.
Never
Two Common Forms of Charting:
POMR - Problem Oriented Medical Record includes chronological record for each visit SOAP - Subjective, objective, assessment, plan
A register of death must be retained:
Permanently
A register of surgical procedures must be retained:
Permanently
The Privacy Act of 1974 provides:
Private citizens some control over information that the federal government collects about them by limiting the use of information for unnecessary purposes.
Confidential information that has been told to a physician (or attorney) by the patient
Privileged Communication
Public Health Services Act:
Protects patients who are receiving treatment for drug and alcohol abuse.
Protects patients who are receiving treatment for drug and alcohol abuse
Public Health Services Act
_____ ______ may establish who owns the medical records
State statutes --most states- physician or owners of a health care facility
Ordered by the Court
Subpoenaed
Using statute of limitation as a guide for retaining records, medical records of a minor would be kept until patient reaches age of maturity plus period of statute. For example:
if age of maturity is 21 then records would be kept until the age of 23
Records should not be released to the patient without the permission of :
The physician
All entries into a medical record should be made as soon as they occur or as soon as possible afterward
Timeliness of Documentation
T/F Legal confidentiality obligations apply to all methods of record keeping
True
If a court requires certain records that document patient care and billing, it can issue:
a subpoena
Which is NOT a guideline to follow regarding court requested material? a. Always turn over the entire medical chart b. Notify the physician that a request has been made c. Notify the physician's attorney tat a request has been received
a. Always turn over the entire medical chart
Which statement is true? a. Some states have passed statutes that define what must be contained in a medical record b. No states have passed statutes that define what must be contained in a medical record c. All states have passed statutes that define what must be contained in a medical record
a. Some states have passed statutes that define what must be contained in a medical record
If a physician is not able to produce a medical record or documentation about treatment of a patient, the court: a. may make an inference of guilt b. will rely instead on testimony, which is just as valid and helpful in court c. will dismiss all charges
a. may make an inference of guilt
Normal as well as ______ or ______ finding should all be noted in the medical record.
abnormal or negative
Medical record management requires attention to _____, ______, ____, and _______.
accuracy, confidentiality, proper filing, and storage
Medical records must be _____ and ______.
accurate and timely.
Minors health records are kept for
age of maturity plus statute
EMR
all patient related data is computerized into one record--more widespread now
The only time they can divulge that the patient is at that facility receiving treatment for alcohol or drug abuse problems is during:
an emergency care that would necessitate divulging the abuse problem
Timeliness of documentation means that all entries should be made:
as they occur or as soon as possible afterward.
Patients must _____ release of their records in writing
authorize
Which statement is true? a. Falsification of medical records is ground for civil indictment b. Falsification of medical records is ground for criminal indictment c. Falsification of medical records is a matter that is handled within an individual medical practice
b. Falsification of medical records is grounds for criminal indictment
Which statement is true? a. All healthcare employees should be able to access all patient records in the computer b. All healthcare employees should not be able to access all patient records in the computer c. To be able to see all patient records is a right of every healthcare worker
b. access all patient records in the computer
What kind of liability may healthcare providers and institutions such as hospital and clinics face for releasing medical records without the proper patient authorization?
both civil and criminal
A healthcare worker must respond to a court order for medical records:
by the due date on the order
Which statement is true? a. The patient should be billed for copying costs of a court requested documents b. The court should be billed for copying costs of a court requested document c. The requesting attorney should b billed for copying costs of a court-requested document
c. The requesting attorney should be billed for copying costs of a court requested document
In the eyes of the court, if something is not documented, it: a. is probably illegal b. is probably insignificant c. wasn't done
c. wasn't done
Hospitals maintain a patient registry at switchboard or front desk. However they _____ divulge that a patient with a drug or alcohol abuse problems is even a patient at that facility
cannot
The medical record is a document that records both the ______ and _______ that a patient did and did not receive.
care and treatment
Some subpoenas may be served by:
certified mail or in person depending on the state. If served in person, only the person named in the subpoena can accept it
Patient has right to see records and request a copy. However, the physician may _____ fees for copies
charge
Anyone processing medical billing records must be conscientious about the accuracy of names, dates and services rendered. Careless documentation for claims of insurance payments can result in physicians being brought up on:
charges of fraud
Not all healthcare professionals will _____ information on a patient's medical record
chart
Patients have legal right of _____ _______ told to their physician and access to their medical records
confidential information
If the attorney has a subpoena, only specific records requested should be _____
copied
Citizens have right to gain access to their records and ____ any of the records, if necessary
copy
Anyone who releases confidential information relating to patients who are receiving treatment for drug and alcohol abuse are subject to:
criminal fines
Many healthcare facilities require all employees to sign a confidentiality agreement. Failure to honor this can result in?
dismissal and possible legal action
Opinion and speculation ____ _____ belong in the medical record.
do not
In the eyes of the court, if it's not ________ it wasn't done.
documented
All corrections on a paper file should be made by:
drawing a single line through the error, writing the correction above the error, dating the change, and then initialing it. DO NOT erase or use correction fluid. The original statement should never be obliterated.
The medical record is a legal document and can be subpoenaed into court as ______ in a malpractice case.
evidence
Late entries into a medical records means the record was ______ for a period of time.
incomplete