© 2013 the mcgraw-hill companies, inc. all rights reserved. ch 7 medical records and informed...

© 2013 The McGraw-Hill Companies, Inc. All rights reserved.

Ch 7Medical Records

and Informed Consent


Learning Outcomes

7.1 Explain the importance of medical records and the importance of correct documentation.

7.2 Identify ownership of medical records and determine how long a medical record must be kept by the owners.

7-2


Learning Outcomes

7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

7.4 Describe the necessity for electronic medical records and the efforts being made to record all medical records electronically.

7-3


Medical Record

• 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

7-4


Purposes of Medical Records

• They are required by licensing authorities and provide a format for tracking, documenting, and maintaining patient communication data.

• They provide documentation of a patient’s continuing health care from birth to death.

7-5


Purposes of Medical Records

• They provide a foundation for managing a patient’s health care.

• They serve as legal documentation in lawsuits.

• They provide clinical data for education, research, statistical tracking, and assessing the quality of health care.

7-6


5 Cs of Documentation

• Concise

• Complete (and objective)

• Clear (and legibly written)

• Correct

• Chronologically ordered

7-7


Question

Tell whether the following statement is true or false.

Photographing or otherwise recording a patient’s image without proper consent may be interpreted in a court of law as invasion of privacy.

True

False

7-8


Answer

True

Photographing or otherwise recording a patient’s image without proper consent may be interpreted in a court of law as invasion of privacy. Invasion of privacy charges are most often upheld in court if the patient’s image was used for commercial purposes.

7-9


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.

7-10


Corrections to Medical Records

• Draw a line through error so it is still legible (do not use white out).

• Write or type in information above or below the line or in margin.

• Note why correction was made.• Enter date and time and initials.• Have another person witness the

correction and add initials if possible.

7-11


Ownership of Medical Records

• Medical records are owned by the facility that created them.

• The patient owns the information they contain.

• On signing a release, patients may usually obtain copies of records under HIPAA ruling.

7-12


Question


Courts have held that in some cases, patients treated for mental or emotional conditions may be harmed by seeing their own records.

True

False

7-13


Answer

True

Courts have held that in some cases, patients treated for mental or emotional conditions may be harmed by seeing their own records. This is covered under the doctrine of professional discretion.

7-14


Retention and Storage of Records

• As protection in event of litigation medical records are kept until specified statute of limitations.– Usually 2 to 7 years

• Most physicians retain records indefinitely as they affect future treatment.

7-15


1-16

State and Federal LawsFor the most part, state and federal laws regarding mandatory record retention requirements apply to hospitals or similar facilities rather than to physician practices. The Medicare Conditions of Participation (COP) require hospitals to retain records for five years (six years for critical access hospitals),1 whereas OSHA requires an employer to retain medical records for 30 years for employees who have been exposed to toxic substances and harmful agents.2 HIPAA privacy regulations require records to be retained for six years from when the record was created,3 which follows the federal statute of limitations for civil penalty


Routine Release of Medical Information

• Insurance claims

• Transfer to another physician

• Use in a court of law

7-17


Fiduciary Duty

• Physician’s obligation to patients based on trust and confidence

7-18


Providing Medical Information for Lawsuit

• Make sure name, phone number of attorney, and court docket number of case are listed.

• Verify the carbon copy is same as original in every way.

• Verify patient named was a patient of the physician named.

• Verify trial date/time on subpoena

7-19


Providing Medical Information for Lawsuit

• 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.

7-20


Alcohol and Drug Abuse

• Confidentiality of alcohol and drug abuse, patient records– Protects patients with histories of

substance abuse regarding release of information about treatment

7-21


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.

7-22


Consent

• The patient gives permission (orally or in writing) either expressed or implied for the physician to examine him or her to perform tests that aid in diagnosis, and/or to treat for a medical condition.

7-23


Informed Consent Information

• Proposed modes of treatment• Why the treatment is necessary• Risks involved in proposed treatment• Available alternative modes of treatment

and risks of these modes• Risks involved if treatment is refused

7-24


Question


Emancipated minors cannot legally give informed consent for medical procedures.

True

False

7-25


Answer

False

Emancipated minors can legally give informed consent for medical procedures. A minor becomes emancipated through a court hearing where evidence is presented that a minor should be emancipated.

7-26


Cannot Give Informed Consent

• Minors, persons under age of majority– Except emancipated minors, married

minors, and mature minors

• Mentally incompetent persons• Persons speaking limited or no English

7-27


Informed Consent Form

7-28


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

7-29


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

7-30


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

7-31


Electronic Health Record

• Contains same information as any medical record, but in electronic form– Cautions regarding confidentiality

• Use of photocopiers• Use of fax machines• Use of computers and printers

7-32

© 2013 the mcgraw-hill companies, inc. all rights reserved. ch 7 medical records and informed...

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