© 2016 McGraw-Hill Education. All rights reserved. Ch 7 Medical Records and Informed Consent

© 2016 McGraw-Hill Education. All rights reserved.. Key Terms addendum Confidentiality of Alcohol and Drug Abuse, Patient Records consent doctrine of informed consent doctrine of professional discretion electronic health record (EHR) fiduciary duty Good Samaritan acts health information technology (HIT) medical record 7-2

© 2016 McGraw-Hill Education. All rights reserved. Learning Outcomes 7.1Explain the purpose of medical records and the importance of correct documentation. 7.2Identify ownership of medical records and determine how long a medical record must be kept by the owners. 7-3

© 2016 McGraw-Hill Education. All rights reserved. Learning Outcomes (cont.) 7.3Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent. 7.4Describe the necessity for electronic medical records and the efforts being made to record all medical records electronically. 7-4

© 2016 McGraw-Hill Education. All rights reserved. Medical Records Collection of data recorded when a patient seeks medical treatment Hospitals, surgical centers, clinics, physician offices, and other facilities providing health care services maintain patients’ medical records 7-5

© 2016 McGraw-Hill Education. All rights reserved. Purposes of Medical Records Required by licensing authorities to track, document, and maintain patient data Provide documentation of a patient’s continuing health care from birth to death 7-6

© 2016 McGraw-Hill Education. All rights reserved. Purposes of Medical Records Provide a foundation for managing a patient’s health care Serve as legal documents in lawsuits Provide clinical data for education, research, statistical tracking, and assessing the quality of health care 7-7

© 2016 McGraw-Hill Education. All rights reserved. 5 Cs of Documentation Concise Complete (and objective) Clear (and legibly written) Correct Chronologically ordered 7-8

© 2016 McGraw-Hill Education. All rights reserved. Consent Form for Patient Imaging Patient knows that imaging will be used to document care Ownership rights belong to the facility but imaging can be viewed or copied Images will be securely stored for specified time period Images will not be released to outside agency without written authorization 7-9

© 2016 McGraw-Hill Education. All rights reserved. Corrections to Written Medical Records Draw a line through the error so it is still legible (do not use white out) Write or type information above or below the line or in the margin Note why correction was made Enter date and time and initials Have another person witness the correction and add initials if possible 7-10

© 2016 McGraw-Hill Education. All rights reserved. Corrections to Electronic Health Records Do not obscure original record Add an addendum –Significant change or addition –Contains: Patient name Date of service Medical record number Original report identified Date and time of correction 7-11

© 2016 McGraw-Hill Education. All rights reserved. Ownership of Medical Records Medical records are owned by the facility that created them The patient owns the information they contain Doctrine of professional discretion –Health care professionals have the right not to release a record if it is in the best interest of the patient 7-12

© 2016 McGraw-Hill Education. All rights reserved. Retention and Storage of Records Medical records are kept until specified statute of limitations –Usually 2 to 7 years Most physicians retain records indefinitely as they affect future treatment 7-13

© 2016 McGraw-Hill Education. All rights reserved. Insurance claims Transfer to another physician Use in a court of law 7-14 Routine Release of Medical Information

© 2016 McGraw-Hill Education. All rights reserved. Alcohol and Drug Abuse Records Federal law protects patients with histories of substance abuse –Specific written permission required –Only the information specifically requested should be released 7-15

© 2016 McGraw-Hill Education. All rights reserved. Providing Medical Information for Lawsuit Make sure name, phone number of attorney, and court docket number of case are listed Verify the copy is same as original in every way Verify patient named was a patient of the physician named Verify trial date/time on subpoena 7-16

© 2016 McGraw-Hill Education. All rights reserved. Providing Medical Information for Lawsuit (cont.) Notify physician that subpoena was received Check that all records are complete Document number of pages in the record and itemize contents Offer sworn testimony on record if so instructed by the court 7-17

© 2016 McGraw-Hill Education. All rights reserved. Authorization to Release Records Authorization should be in writing It should include patient name, address, and date of birth The patient or guardian should sign the authorization Only information specifically requested should be released Patient may rescind consent 7-18

© 2016 McGraw-Hill Education. All rights reserved. Consent Permission from a person, either expressed or implied, for something to be done by another In health care, consent is permission to: –Examine the patient –Perform tests that aid diagnosis –Treat the patient 7-19

© 2016 McGraw-Hill Education. All rights reserved. Doctrine of Informed Consent Outlined in a state’s medical practice acts –Proposed modes of treatment –Why the treatment is necessary –Risks involved in treatment –Available alternatives to treatment –Risk of alternatives –Risks involved if treatment refused 7-20

© 2016 McGraw-Hill Education. All rights reserved. Who Cannot Give Informed Consent Minors, persons under age of majority Mentally incompetent persons Persons speaking limited or no English 7-21

© 2016 McGraw-Hill Education. All rights reserved. Informed Consent Form 7-22

© 2016 McGraw-Hill Education. All rights reserved. Informed Consent and Abortion Law States impose a variety of restrictions Best to stay informed about current law in respective state Can check various websites for most current information 7-23

© 2016 McGraw-Hill Education. All rights reserved. Informed Consent and HIV testing State public health law varies for HIV testing –Permission from legal guardian (may be a parent) required for infants and young children –Married minors, emancipated minors, and minor parents may have the right to consent to testing 7-24

© 2016 McGraw-Hill Education. All rights reserved. When Consent is Unnecessary Emergency situations Good Samaritan acts Give care in good faith Act within scope of training and knowledge Use due care under circumstances Do not bill for services 7-25

© 2016 McGraw-Hill Education. All rights reserved. Health Information Technology The application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision-making 7-26

© 2016 McGraw-Hill Education. All rights reserved. Government Steps Adopting HIT The Health Insurance Portability and Accountability Act (HIPAA) Executive orders Adoption of the Health Information Standards developed by Health and Human Services (HHS) Use of the federal government to foster the adoption of Health Information Technology 7-27

© 2016 McGraw-Hill Education. All rights reserved. HIPAA Disaster Recovery Plan –Specifies resources, actions, personnel, and data that are required to protect and reinstate health care information in the event of a disaster How operations will be conducted in disaster Who is responsible for what How data will be moved without violating confidentiality and security How data will be restored 7-28

© 2016 McGraw-Hill Education. All rights reserved. Technological Threats to Confidentiality Electronic transmittal of records Photocopiers Fax machines Computers –Monitors –Destroy records on hard drives when computer is sold or recycled Printers 7-29