Chapter 6—Medical Records and Informed Consent PowerPoint to accompany Law & Ethics For Medical Careers Fourth Edition Judson · Harrison · Hicks Chapter 6—Medical Records and Informed Consent Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display 6-1

Medical Records and Informed Consent OBJECTIVES Explain the purpose of medical records and the importance of proper documentation Demonstrate how to correct entries in a medical record Discuss ownership and record retention issues Discuss informed consent State the purposes of the Good Samaritan Act and the Uniform Anatomical Gift Act

Purposes for Medical Records Required by licensing authorities Provide documentation and continuity of care Provide a foundation for managing the patient’s healthcare Serve as a legal document/record May provide clinical data for education and research

Medical Record Entries Entries in the medical record must be Objective Concise Legible Entries should never include inappropriate statements or attempts at humor

Medical Record Contents Clinical Medical history Symptoms Examination, assessment & diagnosis Treatment Documentation of instructions Test results Prescriptions & Refills Administrative Full name and demographics Informed consent if appropriate Documentation of phone calls Other medical records

Medical Records and Patient Imaging Patient images (photographs, videotapes, digital images) are subject to the same written release requirements as the rest of the medical record Release of any patient images without consent may be interpreted as an invasion of privacy by the courts

Correcting the Medical Record Inappropriate correction to a medical record could be interpreted as evidence of guilt in a medical malpractice case Errors noted after the fact should be corrected by drawing a single line through the mistake, writing in the correction, initialing, and dating the correction

Ownership of the Medical Record The physical record is the property of the entity that created it: Physician office Clinic Ambulatory Surgery Center Hospital Content of the record is owned by the patient HIPAA is discussed in Chapter 7

Medical Record Retention Records should be kept until applicable statute of limitations has expired Statutes vary from state to state Two to seven years Records are also kept for tax and liability reasons

Medical Record Confidentiality Medical records should never be released to a third party without permission of the patient or patient’s guardian HIPAA covered in Chapter 7

Technological Threats to Confidentiality Copiers Don’t leave medical records near the copier Shred unwanted medical records Clear paper jams Fax Machines Fax cover sheet should have a confidentiality statement

Technological Threats to Confidentiality-continued Computers Monitors should be out of view of others Sending medical records by e-mail is not recommended Printer Records should be printed to a printer that is in a secure area and is not a general use printer

Release of Information Guidelines Should be in writing Should include patient name, address and date of birth Patient or legal guardian should sign and date Release only information specified Patient has right to rescind release

Release of Information Guidelines continued State legislation may include specific release guidelines regarding Mental health HIV testing Substance abuse Federal law also protects confidentiality of alcohol and drug abuse patient records

Subpoenas duces tecum Medical malpractice Other reasons Verify information carefully Contact your attorney Provide all records as required Remove medical record from established files Other reasons Worker’s comp, auto accidents, general accidents Be certain physician is not named as defendant Copy records and mail Invoice for copies

Informed Consent Six elements of informed consent require that patient understands Proposed modes of treatment Why the treatment is necessary Risks involved in the proposed treatment Available alternative modes of treatment Risks of alternative modes of treatment Risks involved if treatment is refused

Informed Consent continued Who cannot give informed consent Minors (except emancipated, married or “mature” minors) Mentally incompetent Those who do not speak or understand English

Informed Consent continued Abortion Law Governed by individual state Constantly changing HIV Testing Individual must be advised of testing Law varies with minors seeking testing Check with your public health officials

Informed Consent continued Good Samaritan Act No consent is necessary in emergency if patient is in imminent danger The act (by state) protects physicians and some other health care practitioners from negligence claims as a result of care Caregiver must act in good faith, within scope of training, use due care and not bill for services

Uniform Anatomical Gift Act (UAGA) States have accepted provisions of UAGA Allows individual to donate body or body parts, after death, for use in Transplant surgery Tissue banks Medical research or education

National Organ Transplant Act Enacted in 1984 to address shortage of organs The Organ Procurement and Transplantation Network (OPTN) maintains only national patient waiting list Run privately, under contract with the US Department of Health and Human Services

Ethics Guide Discussion Are you an organ donor? Why or why not? You are employed in an internist office. The spouse of a good friend is a patient. He comes in for HIV testing. Are you going to tell his wife (your good friend)? What if the patient above is your sister-in-law?