Medical records and the law
The medical record refers to the information that is retrieved from the patients by the medical officer when a person falls sick is administered in the hospital. This information is very vital since it reveals that true status of the patient in terms of the disease the patient is suffering from. The medical information is also very necessary especially when a patient visits a new hospital that he or she has never visited before since it gives the prevision information concerning the medication that the patient was previously treated from in the medication centre. This gives directions to the new doctors and the nurses to use appropriate medication in the treating of the patients thus making sure that the medication that is used by the patients does not react with the patient but treats the intended disease thus making the patient to get well and health back to the normal living body conditions. Since the medical record encompasses of the vital information concerning the patients that are being administered in the hospitals, the information should be safeguard and protected from the access by the authorized personal.
The medical information can be protecting from the access of the authorized access from the intruders and other people by the law which was enacted to keep the documents safe until needed back by the patients or the relations to the patients. This makes it possible to store the information in privacy unless the information is needed by the government and the federal for research and other governmental bodies (Abdelhark & Fahima 112). The medical data is usually obtained from the sick patients the moment they are administered in the clinical centers for the main purpose of being keeping the patient at safe condition.
The medical information collected from the patients in the hospital is very critical and crucial information concerning the patients. This type of data is actually personal meaning that it should only be accessed by the doctors and the patients who is being treated in the hospital. The medical data can also concern information concerning the financial status of the sick patient. This is very vital and in most medical centers since the patient that will be administered in the medical place is supposed to cater for the bills and medication that has been used to treat him or her in the medication centers. In other hospitals and medical centers the medical information that has been received from the patients at the counters before being treated in the specific medical centers might include the facility status of the patient that is yet to get treatment (Roach, Chernoff & Eslay 143).
Types of records
The types of records that are stored in the medical centers concerning the patients might be categorized into various sub-divisions basing on how critical and vital the information is on the patient that is being admitted in the hospital. There are four main types of information that are stored in the medical record which encompasses the personal information, the financial status of the sick patient, the previous medical condition of the patient and the social aspect of the patient. The information is usually filled into a medical sheet thus making it very simple to stored and retrieve it at any given moment as long as it is needed either for meditational purposes or by the federal police who might need the information for research purposes. This medial record that is stored in the medical centers usually encompasses of the information concerning the patient such as the full names of the patient which is the first name and the surname to make sure that the patients that are administered are truly the ones indentified by the names given.
Other details that are contained in the medical record include the date of birth and the location that the patient is born, the sex of the patient which is either male or female making it possible for the patient to be assigned the required wards before getting treated. Marital status and information is also essential data that is collected from the patient to be given to the doctors and the nurse in the medical centers since they assist the couple that is not sick might give additional information that is very vital concerning the sick patient. The place at which the sick person works is also very important thus should be included in the medical records to ensure that the other and the employer is notified by the hospital official concerning the medical condition of the sick patient incase they were not informed that their working mate is ill and has been admitted in the specific medical centre (Lyman, Fahima & Watzlaf 162).
The kin of the sick patient is also very vital since it gives vivid information whether the patient might have got the disease from the hereditary cycle of the ancestral relationship. This is especially common to patients suffering from diseases such as cancer and other hereditary diseases. The other information that is usually indicated in the medical record of the sick patient includes the data that reveals the person or the physicians that is assigned to treat the given patient. This is very essential since the patient might be treated in an appropriate manner by the physician and take legal actions that might require the arrest of the physician who treated the patient.
The social information that might stored in the medical records concerning the sick patient might encompass of the race of the sick patient, the lifestyle that the patient was living before being attacked by the diseases, the family relationship that the patient has especially whether he or she stays alone or together with family members, the position that the patient holds in the society and the communal activities that the patient performs when in a normal body condition. Other data that might recorded in the medical records of any given patient that might be admitted in the any given medical centers and hospital include the ward number that the patient will be admitted in, the duration in which the patient will stay in the hospital for the main purpose of being offered medication and treatment from the given hospital. The final medical record also contains information concerning the specific disease that the patient is suffering from. In general the information that is stored in the medical records are very vital since they concern the entire life of the sick patient thus it should be strictly kept out of access of the unauthorized people (Merida 119)
Importance of medical records
The medical records are very essential in various ways both to the patient that is yet to be admitted to any medical centre and to the doctors who will offer treatment to the given patient. To the patient the recorded medical information is very vital in the sense that it will enable him or her get appropriate treatment facilities that will also make him or her receive the good health back to the normal standards. To the doctors and the nurses in the hospitals or the medical centers, the medical information that is recorded is very essential since it enables the doctor to identify the diverse diseases that the patients was suffering from before and thus giving a clear history of the diseases that were affecting the patients in the past. The medical data is also very beneficial to the medical centre in general since it enables the medical centers to be able to fully recognize the patients that are yet to be treated. This makes the entire management of the medical centre to be assured on the payment of the treatment fees.
Legal requirements for content of medical records
The legal requirements of the medical record imply that the medical record stores information concerning personal, financial and medical overview of the patients. Basing on these facts it is true to state that the medical inform should be stored as a private property since it is vital information concerning only a single person who is the patient. This information should not be exposed to the unauthorized people like the occasional visitors in the hospital since they might be enemies to the patient suffering in the medical center thus make the patient even weaker than getting better. The spread of the information concerning the patient might also make the patient get wrong reputation from the friends and the workmates depending on the disease the patient is suffering from and the cause of the disease. From this reasons, the legal laws were enacted to make sure such information is not spread all over the people who are not concerned at all (Abdelhark, Mervat, & Fahima 156).
Records retention requirements
The medical record that contains the information of the patients that are admitted in the hospital is very vital even after the patients are released from the medical center. This is because the medication that might be used to treat the patient might have various side effects that might even cause the death of the patients because of the outcome that might have been released by the impact of the medication given. For this reasons, the law was enacted to protect the patients in a manner that the patients are able to use the information that was delivered from the documentation of the medical record to sue the physician that treated him or her during the duration in which the patient was sick. The joint commission is the main body that stores the information for a long duration of about seventy five years before the information can be demolished or termed to be useless. However, the state law also requires the same information but it is not for along duration of time like that of the joint commission. The state law requires the medical records for only duration of five years only.
Destruction of the records
The medical record concerning the basic information of the patients that are admitted in the hospital might only be destroyed after a period of seventy five years from the time the patient was admitted in the medical centre and released out for the main purpose to get well soon from the outside of the health care home especially at home. This is mainly because after seventy five years, the medical record would have lost meaning in the life of the patient and it could still be a very long duration of time that cannot be used to be referred in the predicting the type of the disease that is affecting the patient. The medical records covering the information of the patients are usually burnt to make sure that they are not reveled to the outside people who are neither the doctors nor the relatives of the patient (Lyman, Fahima & Watzlaf 120).
Importance of a legible and complete medical record
The medical record information is a very vital document concerning the information of the patients thus it should be written in legible writings to enable any doctor or officer to be able to read with easy and understand the document in an appropriate manner. The management of the medical centre should also make sure that the medical record document is well organized in the manner that it is whitened and it should be completed by the patient when filling since it gives vital information that is very important to both the patient and the hospital at large.
Access to the medical record by or on the behalf of the patient
The medical record document can be only accessed by the patient and the doctor that is in charge of treating the patient in the medical centers. This is because the information encompasses of the vital information concerning the patient thus when it is revealed to other people in the hospital or outside the hospital might cause threat to the patient after he or she has been treated and released out of the medical centre. The exposure of the medical records to the outside world might also be the major cause of the death of various patients since it might be a shock to the patient. For this reasons, the joint commission was established to endure that the medical information concerning the patients are only available to the patient and the doctor not anybody else apart from the two (Roach, Chernoff, & Eslay 157).
Record of the abortion cases should also be kept as a secret between the doctor and the patient unless the case is the presented to the court which will require the evidence from the medical records. The medical record concerning the patients who were affected with drugs such as alcohol and other drugs should also be kept a secret just like other information concerning the patients since the exposure of such information might be like an abuse to the patients thus demoralizes the entire healing process of the sick patients. The psychiatric record and the record containing information concerning the data of the minor should be also a secret to the physicians who are involved in the treatment of the patients and the patients only since it contains information concerning the sick patients.
However, the medical record information might be exposed to other parties such as the relationships of the patients such as the parents and the wife incase the patient is a minor or insane respectively. The medical record data can also be reveled to other bodies such as the federal police for the main purpose of researching more information concerning the cause of the disease of the patient or the social life of the patient before he or she was admitted in the medical centre for the main purposes of being ill. The medical records concerning the special data of the patients who are admitted in the hospitals can also be revealed to the outside of the hospitals or to other people apart from the physicians and the patient when the data is needed for the main purpose of undertaking a research concerning the diseases that is being treated from the patient. This is especially in cases of the diseases that keep on changing from one patient to another because of the adaptive nature of the virus or the bacteria that causes the disease. For instance the virus that causes the disease of HIV/AIDS disease keeps on changing from one patient to another thus the need to study the viral from the blood that is obtained from one patient to another. Apart from the given option that are discussed, there are no other people who have the allowance to view the detailed that are recorded in the medical form since it is strictly for the patient and the physician who is treating the patient.
Other hospital staff members such as the cooks and the cleaning workers found frequently in the ward and the offices of the doctors also have no authority to access the information concerning the patients since they are not part of the treatment department of the office even though they are part of the hospital. For this reasons, most of the hospitals usually have a fixed and constant fee that they normally charge their patients for the main reasons to afford the security that the patients medical record are kept safe in places where unauthorized personnel can not get easy access to the documents. This record fee is normally considered to be seventy five percent of the total fees that is paid for admission. The duplicate fee for the medical document is normally 75 cents per page though it is given to patient for free if at all the patients needs the copy of the document (Merida 177).
Response to legal process
The legal processes involves the various methods that the medical information might be allowed to be viewed with the federal or the court in situation that area allowed by the court. The medical records are also taken as official documents that can also be offered to the police or be presented in the law courts as a piece of evidence especially in cases where the patient might be judged guilty and yet he or she was still undertaking medication from the hospitals thus unable to attend the court proceedings. For instance, the hearsay which is a medical record statement that is usually made outside the court and then later is introduced into the court but when it is implemented, there is usually an exception in the sense that the cross examination rights are normally lost.
The hospitals are at all time taken responsible when the information in the medical records are revealed out to the public since these information is usually supposed to be stored in a private place were only the patients and the doctors can get access of the documents. The medical record in the hospitals are usually protected by the committees which are usually created in most of the hospitals just to ensure that the data is kept as private as possible and at the same time the information is not lost (Tour, Fahima & Maki 184). The discovery of the data that the various committees in hospitals such as the tissue committee, and the view committee to other bodies such as the public or destruction might be to some extend is forgiven by the courts ruling especially when the medical records are lost through an accidental manner such as a hospital emergency fire brake out. Therefore, the medical records in the hospitals are usually protected in appropriate manner unless the information is lost in other unavoidable circumstances such as accidental fire breakouts.
Consents Documentation of patient’s in the medical record.
An inform consent is the information that is given to the patient before the patient is treated from other diseases since the outcome of the disease or the treatment might have several outcomes to the patients. This is very vital since the patient might undergo various difficulties thus become unable to function in an appropriate manner or even might end up being paralyzed or even die from a certain treatment offered to him or her by the hospitals. Thus the consents documentation of patients is normally included in the medical records to ensure that the hospital is not taken responsible for such incidents. The consent information is usually offered by the nurses who are in charge of treating the patient since he or she is well versed with the consequences that are offered by the hospital.
There are three main consent forms that the patients are supposed to fill after being advice about the treatment in which they are supposed to receive. This encompasses of the blanket consents form, detailed consent foam and the battery consent form. The battery consent encompasses of the main procedures of the treatment and the patient is usually well versed with the information and the risks that might take place in the procedure. This might include the consequences and the procedure of the therapy that might be used in the treatment of the patient. The blanket consent form encompasses of the authority that the doctor receives from the patient that basically offers the physicians an okay in the performance of the medical treatment. The detailed consent forms includes all the other medical performances such as the procedures to be followed in the treatment processes, the alternative treatment that might be taken for the medication incase the one being used fails, the consequences and the risks offered by the treatment to the patient (Roach, Chernoff & Eslay 119).
Finding principles of hospital liability
Negligence is the state in which the management of the hospital takes risks and decline to take good care of the patients in the hospital scene. This is because the patients in a given hospital might be too many than the working staff of the doctors thus forces them to offer poor services that are below the required standards for the treatment of the patients. While the principles of hospital liability encompasses of the principles of charitable immunity that the hospital achieve especially by being cleaned from non-profitable liabilities and in most cases might be followed by gifts and donations which might be offered to the hospitals. The hospitals key duty is to ensure that the patients are properly treated and their record well stored for future references incase the disease reoccurs again.
The standards of the services that are offered by the hospitals should also be measured and checked at all times to ensure that the patients are receiving adequate treatment from the physicians and the nurses. This is usually tested by the breach of duty which is used to give vivid evidence that the information that is offered by the hospital towards the treatment of the patient was appropriate. This in common hospitals is usually offered by the testimony that is delivered by an expert. Statues and regulations is another form of evidence that the hospital is offering standard care to the patients. The hospital policies are also enacted to ensure that the evidence of the standard of the hospital care is true. Res Ipsa Loquitur which is a doctrine that the court uses to defend the patients especially when not well informed about the injuries that might be obtained from the treatment (Tour, Fahima & Maki 195).
Work cited
Abdelhark , Mervat, & Fahima, P. Health Information Management of a Strategic Resource,London: Evolve Elsevier publishers, 2007
Lyman, Elizabeth, FAHIMA., Watzlaf, Valerie., Fahima. Health Informatics Research and Methods Principles and Practice, California: AHIMA Publishers, 2009
Merida, Johns. Health information Management Technology on Applied Approach, California: AHIMA Publishers, 2007
Roach, William., Chernoff, Susan., & Eslay, Carole. Medical Records and the Law, New York: Aspen publishers, 1985
Tour, Kathleen., Fahima & Maki, Shirley. Health Information Management, Concepts, Principles and Practice, California: AHIMA, 2010
