Patient Rights, Medical Information & Records: a JCI Perspective October 10, 2007 Makati Medical Center ATTY. RODEL V. CAPULE MD FPCEMAC FPCP Professor & Consultant, Legal Medicine

Objective To familiarize all physicians on the provisions of JCI related to patient’s right to privacy, medical records and medical information. To understand patient’s right to privacy and confidentiality of health information. To understand the legal issues related to medical records.

Standard PFR.1.6 Patient information is confidential.

Intent of PFR.1.6 Medical and other health information is important for understanding the patient and his/her needs and for providing care and services. Medical and other health information is documented: 1. in paper form 2. in electronic form 3. or combination of the two

Duties of the hospital Respects medical and other health information as confidential. Implements policies and procedures that protect such information from loss or misuse. The policies and procedures reflect information that is released as required by law and regulations. The hospital has a policy that indicates if patients have access to their health information and the process to gain access when permitted.

Duties of staff Aware of laws and regulations governing confidentiality. Inform the patient about how the hospital respects the confidentiality of information Patients are informed about when and under what circumstances information may be released and how their permission will be obtained.

Respect for patient confidentiality Not posting confidential information on the patient’s room. Not posting confidential information at the nursing station. Not holding patient-related discussions in public places.

Definition Right to Privacy Duty to respect Confidentiality Duty to breach Confidentiality Privileged communication

Right to Privacy Right to be left alone. Owned by the patient. No person can access any information about a patient without his consent.

Duty to respect confidentiality Duty is imposed on the health care provider. (includes the hospital) All information should be kept secret by the physician, even those acquired from other parties. Promotes truth telling on the part of the patient.

Duty to breach confidentiality Reportorial duty of health care provider Impose by law- Act 3573 “Law on Reporting of Communicable Diseases” (1929); PD 169 as amended “Requiring Doctors, Hospitals, Clinics, etc. to Report Treatment for Physical Injuries” (1987) ; PD 603 “…reporting of child abuse case within 48 hours” Exercise of police power- public health protection Protection of third parties- Tarasoff v. Regents of University of California 131 Cal.Rptr 14 (1976)

Privileged Communication Rule of admissibility (Rule 130 sec 24 (c) Rules of Court) Disqualification by reason of privileged communication – The following persons cannot testify as to matters learned in confidence in the following cases: (c) “ A person authorized to practice medicine, surgery, or obstetrics cannot in a civil case, without the consent of the patient, be examined as to any advice or treatment given by him or any information which he may have acquired in attending such patient in a professional capacity…”

Release of medical information Release during confinement: - queries from relatives, friends, media, police authorities. Release after confinement: - patient, authorized representatives, police authorities, insurance companies, courts

Directory Information Name Name Location Location Medical status Medical status Religion Religion

Requirement before release of directory information The first and last name must be recited by the asking party. Consent of patient.

Release of Location Should not be released if it would embarrass the patient.

Release of AP’s name Case to case basis. Not advisable if specialty practice of AP would embarrass the patient.

Release of medical records to other parties General rule: should be released only to the patient himself Release to other party: - authorization from the patient - only relevant records

Release via fax/ Record the phone number or address on the chart. If by fax, specify what time it should be sent. Specify if it can be receive by other persons.

Who owns the medical record? The physical medical record/chart (includes all diagnostic films, slides, tracings, reports etc.) is owned by the hospital. Ownership interest on the information: 1. hospital 2. physician 3. patient 4. insurance company 5. courts 6. police authorities

Hospital Medical Records Management Manual DOH 2 nd ed “For medical records ownership is not absolute, because the patient also has a right to the information written on the record, that being his health history.” - Chapter 6 page 67

Who can write entries in the medical chart? Hospital determines who can write in the medical chart. Licensed healthcare provider Interns, medical students (?)

Department of Medical Records Department of Medical Records Duties: 1. custodian 2. protects the record from the elements 3. protects the record from pilferage, loss and misuse 4. destruction of records 5. certifies duplicate copies

Right to access the medical chart during confinement Access is granted within a reasonable time. Chart must be complete. Patient must not be left alone with the chart.

Right to access medical chart confinement Right to access medical chart after confinement Access is granted within a reasonable time. Chart must be complete. Patient must not be left alone with the chart.

Medical record entries Legible and complete medical record entries. Timely medical record entries. Authorship and countersignatures. Authentication of records/auto- authentication. Verbal orders. Corrections and alterations.

Admissibility of medical records Rule 130 sec. 43 (RRC) Can be received as prima facie evidence even if the person is deceased or unable to testify. Requirements: 1. entries made at, or near the time of transactions to which they refer. 2. person was in a position to know the facts there in stated. 3. entries made in his professional capacity or in the performance of a duty. 4. entries made in the ordinary or regular course of business or duty.

The End