1. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Medical Law and Ethics The Medical Record Chapter 9

2. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. The Medical Record All written documentation relating to patient Includes – Past history – Current diagnosis and treatment – Correspondence relating to patient Is a legal document May be subpoenaed

3. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Purpose of the Medical Record Record of patient from birth to death Document for continual management of patient’s health care Provides data and statistics Tracks ongoing patterns of patient’s health

4. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Figure 9.1 A Medical Records Filing System

5. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Contents of the Medical Record Personal information about patient Clinical data or information – Records of medical examinations – X-rays – Lab reports – Consent forms – Referrals: PT/OT – Prescriptions and refills

6. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Figure 9.2 Example of SOAP Charting

7. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Two Common Forms of Charting POMR: Problem-Oriented Medical Record includes chronological record of each visit SOAP: subjective, objective, assessment, plan – Subjective statements of patient – Objective data such as lab reports, vital signs – Assessment or diagnosis – Plan of treatment

8. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Corrections and Alterations Draw one line through error Write correction above error Date and initial change Do not erase or use correction fluid Falsification of medical record is grounds for criminal indictment

9. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Figure 9.3 Example of Corrected Chart Notation

10. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Timeliness of Documentation Medical records must be accurate and timely All entries must be made as care occurs or as soon as possible afterward Should be completed by physician within 30 days following patient's discharge from hospital

11. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Completeness of Entries Medical records document type and amount of patient care that was given In eyes of court, “if it’s not documented, it wasn’t done”

12. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Confidentiality Medical records should not be released to a third party without patient’s written consent Only specific records requested should be copied and sent Taking photos or other visual images of patient without consent is invasion of patient’s privacy

13. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Ownership Physicians or owners of health care facility own the medical record Patients have legal right of “privileged communication” and access to records

14. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Ownership (continued) Patients must authorize release of records in writing Doctrine of professional discretion: physician may determine, based on his or her best judgment, if patient with mental or emotional problems should view medical record

15. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Release of Information Never send entire medical chart unless it is requested Do not send original

16. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Release of Information (continued) Record may not be released to patient without physician’s permission Patient must sign release form for information to be sent to insurance company

17. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Privacy Act of 1974 Agency may maintain only information relevant to its authorized purpose Citizens have right to gain access to records and to copy records if necessary Applies only to federal agencies and government contractors

18. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. State Open Record Laws Some states have freedom of information laws that grant public access to records maintained by state agencies Medical records generally are exempt from this statute

19. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Alcohol and Drug Abuse Patient Records Public Health Services Act protects patients who are receiving treatment for drug and alcohol abuse Person or program that releases confidential information relating to these patients is subject to criminal fines Exception if patient should require emergency care

20. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Retention and Storage of Medical Records Each state varies on length of time records must be kept Legally, records must be stored for a minimum of ten years from time of last entry Minor’s records must be kept until patient reaches age of maturity plus period of the statute of limitations

21. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Storage Current records usually kept within physician's office May rent storage space May be placed on microfilm Kept in fire-proof, locked area

22. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Figure 9.4 Medical Records Storage Unit

23. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Computerized Medical Records Data on patient records can be created, modified, authenticated, stored, and retrieved by computer Special safety measures should be taken to establish personal identification and user verification codes for access to records Should be accessed on need-to-know basis

24. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Reporting and Disclosure Requirements State laws require disclosure of some confidential medical record information without patient’s consent Reporting and disclosure are duties of the physician

25. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Use of Medical Record in Court Improper Disclosure: health care providers and institutions may face civil and criminal liability for releasing medical records without proper patient authorization Subpoena Duces Tecum: written order requiring person to appear in court, give testimony, and bring information described in subpoena