© 2013 The McGraw-Hill Companies, Inc. All rights reserved. Ch 7 Medical Records and Informed Consent

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. Learning Outcomes 7.1Explain the importance of medical records and the importance of correct documentation. 7.2Identify ownership of medical records and determine how long a medical record must be kept by the owners. 7-2

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. Learning Outcomes 7.3Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent. 7.4Describe the necessity for electronic medical records and the efforts being made to record all medical records electronically. 7-3

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

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

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

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. 5 Cs of Documentation Concise Complete (and objective) Clear (and legibly written) Correct Chronologically ordered 7-7

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

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

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

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

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

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. Question Tell whether the following statement is true or false. 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

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

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

© 2012 The McGraw-Hill Companies, Inc. All rights reserved State and Federal Laws For 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 1 2 3

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. Routine Release of Medical Information Insurance claims Transfer to another physician Use in a court of law 7-17

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. Fiduciary Duty Physician’s obligation to patients based on trust and confidence 7-18

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

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

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

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

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

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

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. Question Tell whether the following statement is true or false. Emancipated minors cannot legally give informed consent for medical procedures. True False 7-25

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

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

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. Informed Consent Form 7-28

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

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

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

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