There are 4 purposes to a medical record: a legal record, a record of health treatment, a communication tool between members of the health care team, and a research tool.
Since the entire medical record (including patient history and physical examination notes) is a legal document, you need to ensure that your documentation is accurate, objective, and legible.
Psychosocial history including occupational or marital issues, sexual behavior, birth control, alcohol and drug history will be in the chart. Health and social histories contain information on relationships, vaccinations, past illnesses, laboratory, treatments, complaints, and medications. It may be discussed in great detail and this intimate information belongs to the patient. It has been shared in a trusting manner with the physician, but cannot be disclosed to anyone without the patient’s express permission. In simple terms, the patient owns all information inside the medical record and that includes the right of allowing others to know what is in the chart. The only exclusion is mental health records where the patient or staff might be harmed by allowing the patient to see records. Ownership of the actual paper or computer program upon which the information is entered belongs to the facility in which treatment was provided.
Strictly speaking, the physician who prepares a patient’s medical record owns that record, while the patient has a right to the information within it. Patients have the right to request copies of their health records and your office should have a policy on the correct procedures for releasing medical records and health information to patients and to other providers. Normally these requests are required in writing and should be spelled out clearly in your patient notice of privacy practice and office procedure manual. The legal issues mentioned are but highlights of an entire set of patient privacy requirements under federal law. Please consult your office Health Insurance Portability and Accountability Act (HIPAA) information polices and procedures for more detailed information that is beyond the scope of this review.
When faced with a lawsuit, good medical records will help refresh the memory and prove if there is a deviation from a standard of care. Standard of care means providing the same quality of care as any other person with the same level of training in an equivalent area. This differs from scope of practice, which refers to the duties or actions a health care worker is allowed to assume based on the laws and regulations of the state or institution where the worker is practicing. Keeping medical records (retention of records) is quite important. In reality, the legal time that they must be saved varies from state to state and depends on the patient’s age. With modern health information storage techniques, however, it is reasonable to retain records indefinitely. As minors reach majority age (21), they can initiate lawsuits and many injuries are not recognized until several years after occurrence. Records for a deceased patient should be retained for insurance and liability issues. The statute of limitations or time during which a person can file a lawsuit differs from state to state. If records are not retained, they must be burned or shredded. Be very careful in disposal of computer information.
The chart should contain every visit, every record of physical examination, laboratory results, diagnostic procedures, hospital discharge summaries, and consultations. No judgments or opinions should be charted, just facts. Missed appointments and any action taken with abnormal lab results should be charted. Phone calls, advice given to the patient, safety instructions, a patient’s ability to return a demonstration, and presence of family members who received instructions need to be included in the chart. In court, if something is not charted, it was not done.
Information documentation is a major source of controversy in today’s world. Computer storage allows information to be accessed in an emergency situation when displaced persons need access to their health records and paper charts are no longer available. With computer records comes the risk of information theft if those records are illegally accessed. Health care data breaches are reported to the Office for Civil Rights only if they equal or exceed 500 breaches. However, the number of breaches has risen in recent years, with 2017 showing the most breaches of any year to date at press time. Further information is available at https://www.hipaajournal.com/healthcare-data-breach-statistics/.
When responsible for transferring records, make certain to send only copies of original material. There must be permission from the patient to transfer records. Patients have the right to receive a copy of their records in the format that is available or that they desire; this may include paper or electronic copies. Records cannot be withheld for nonpayment of a bill, but a reasonable charge to photocopy can be charged. On occasion, the court will ask for records. This is called subpeona duces tecum. Never take the original chart. Make certified copies of the requested information and nothing more. Copy and number the pages and place them in a folder. Place a prepared table of contents in the front of the file. Lock the original document in the office safe. Obtain a notarized statement that the chart is a reproduction of the original made by the physician’s staff. Take it all to court on the appointed day and time. Do not give it to anyone other than the judge. Obtain an official receipt and be prepared to testify if necessary.