1. Journal Topic: What are the five purposes of the medical record.9
Journal Topic: What are the five purposes of the medical record.

2. Learning Objectives Define the key terms.
List five purposes of the medical record.
List seven requirements for maintaining medical records as recommended by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
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3. Learning Objectives Discuss guidelines for effective charting.
Discuss what is meant by timeliness of charting and why it is important in a legal context.
Describe ways to protect patient confidentiality that relate to the use of fax, copiers, , and computers.
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4. Learning Objectives
Discuss the time periods for retaining adults’ and minors’ medical records, fetal heart monitor records, and records of birth, death, and surgical procedures.
Explain 13 guidelines to follow when a subpoena duces tecum is in effect.
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5. Learning Objectives
Describe confidentiality obligations using electronic medical record keeping.

6. The Medical Record
All written documentation relating to patient, including:
Past history
Current diagnosis and treatment
Correspondence relating to patient
A legal document
May be subpoenaed

7. Purpose of the Medical Record
Record of patient from birth to death
Document for continual management of patient's health care
Provides data and statistics
Tracks ongoing patterns of patient's health

8. Contents of the Medical Record
Personal information about patient
Clinical data or information
Records of medical examinations
X-rays
Lab reports
Consent forms
Referrals: PT/OT
Prescriptions and refills
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9. Contents of the Medical Record
Admitting diagnosis
Evidence of a physician examination
Not more than seven days before admission or 48 hours after admission to a hospital
Documentation of any complications
Signed consent forms
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10. Contents of the Medical Record
Consultation reports
Physicians' and healthcare professionals' notes
Discharge summary, with follow-up care
Should never contain irrelevant material

11. Corrections and Alterations
Errors require correction
Nothing should be deleted
Note in the margin of the record why the change was made
Use black or blue ink
Draw one line through error
Write correction above error
Date and initial change
Do not erase or use correction fluid
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12. Corrections and Alterations
Electronic medical record (EMR) corrections
Falsification of medical records is grounds for criminal indictment

13. Timeliness of Documentation
Medical records must be accurate and timely
All entries must be made as care occurs or as soon as possible afterward
Should be completed by physician within 30 days following patient's discharge from hospital

14. Completeness of Entries
Medical records document type and amount of patient care that was given
In eyes of court, "if it's not documented, it wasn't done"

15. Credibility Believable or worthy of belief, trustworthy, and reliable
Credibility gaps
Other problems
Illegible handwriting
Delays in placing tests and results into file
Any contrived or invented documentation

16. Ownership
Physicians or owners of health care facility own the medical record
Patients have legal right of "privileged communication" and access to records
Patients can be given a copy of their medical record
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17. Ownership Patients must authorize release of records in writing
Doctrine of professional discretion
Physician may determine, based on his or her best judgment, if patient with mental or emotional problems should view medical record

18. Confidentiality
Medical records should not be released to a third party without patient's written consent
Only specific records requested should be copied and sent
Taking photos or other visual images of patient without consent is invasion of patient's privacy

19. Release of Information
Never send entire medical chart unless it is requested
Do not send original
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20. Release of Information
Patient must always sign release form
Only a patient can authorize the release of his or her own medical records
Record may not be released to patient without physician's permission
Patient must sign release form for information to be sent to insurance company

21. State Open Record Laws
Some states have freedom of information laws that grant public access to records maintained by state agencies
Medical records generally are exempt from this statute

22. Alcohol and Drug Abuse Patient Records
Public Health Services Act
Protects patients who are receiving treatment for drug and alcohol abuse
Person or program that releases confidential information relating to these patients is subject to criminal fines
Exception if patient should require emergency care

23. Retention and Storage of Medical Records
Each state varies on length of time records must be kept
Legally, records must be stored for a minimum of ten years from time of last entry
Minor's records must be kept until patient reaches age of maturity plus period of the statute of limitations
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24. Retention and Storage of Medical Records
Due to limited storage space, medical records may have to be destroyed after a period of time has elapsed
There are certain considerations for the methods of destruction

25. Storage Current records usually kept within physician's office
Former patient records may be stored elsewhere
May rent storage space
May be placed on microfiche
Kept in fire-proof, locked area

26. Electronic Medical Records
Data on patient records can be created, modified, authenticated, stored, and retrieved by computer
Special measures should be taken to establish identification and user verification codes for access
Passwords
Encryptions
Firewalls
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27. Electronic Medical Records
Should be accessed on need-to-know basis
Not everyone in a healthcare facility should have authorization

28. Loss of Medical Records
Frustrating, even harmful to all involved
Safeguards can be implemented
Journals
Color-coded inserts or other indication
Designate a sole individual responsible for maintaining records
Microfiche "back up"

29. Reporting and Disclosure Requirements
State laws require disclosure of some confidential medical record information without patient's consent
Reporting and disclosure are duties of the physician

30. Use of Medical Record in Court
Improper Disclosure
Health care providers and institutions may face civil and criminal liability for releasing medical records without proper patient authorization
Subpoena Duces Tecum
Written order requiring person to appear in court, give testimony, and bring information described in subpoena