1. Lesson 3: Medical Records
Privacy and Security
Lesson 3: Medical Records

2. Lesson 3– Medical Records
Personal information, such as full name, phone number, address, work number and address, birth date, social security number, and marital status
Medical history
Description of symptoms
Diagnoses
Treatments
Prescriptions and refills
Records of patient’s telephone calls
Name of legal guardian
Name of power of attorney
Notes about copies of medical records
Medical Records
Medical records are a privileged communication. Medical records contain the following information about a patient:
Personal information, such as full name, phone number, address, work number and address, birth date, social security number, and marital status
Medical history
Description of symptoms
Diagnoses
Treatments
Prescriptions and refills
Records of patient’s telephone calls
Name of legal guardian
Name of power of attorney
Notes about copies of medical records

3. Lesson 3– Ownership of Medical Records
Medical records belong to health care providers, but patients have the right to see and obtain a copy of their records.
Patients with mental illness may not have the right to see their medical records.
If a patient’s employer or prospective employer pays for a job-related physical examination, the employer, not the patient, has the right to see and obtain a copy of the records.
Ownership of Medical Records
Medical records belong to health care providers, but patients have the right to see and obtain a copy of their records. The exception to this is patients with mental illness. This is because knowledge of their medical information may make such patients’ condition worse. In addition, if a patient’s employer or prospective employer pays for a job-related physical examination, the employer, not the patient, has the right to see and obtain a copy of the records. In this case, the employer must give permission for the patient to see and obtain a copy of the records.

4. Lesson 3– Proper Maintenance
Medical records must be complete, legible, and timely.
All information in records must be objective and the information must be initialed and dated.
Errors should never be erased or covered with correction fluid. Instead, a single line should be drawn through an error so that the error is still readable.
Proper Maintenance
Medical records are legal documents. Therefore, they must be properly maintained. Specifically, medical records must be complete, legible, and timely. In addition, all information in records must be objective and the information must be initialed and dated. Subjective observations made by health care workers should never be included. On the other hand, subjective statements made by patients may be included. These should be recorded in patients’ exact words and quotation marks should surround them.
Furthermore, errors should never be erased or covered with correction fluid. Instead, a single line should be drawn through an error so that the error is still readable. And the word “error” should be written and initialed. An explanation of the error may be included. Then, correct information may be inserted, initialed, and dated.
Records should also be kept for at least two to seven years, according to federal and state laws. When records are destroyed, they should be shredded.

5. Privacy and Security
Lesson 4: Technology

6. Lesson 4– Electronic Medical Records
Advantages:
Instant access
Remote access to up-to- date information
Simultaneous access
Decreased time to record information
Legible
Better organization
Flexible data layout
Automated checks and reminders
Increased privacy and decreased tampering, destruction, and loss due to required authorization
Electronic Medical Records
Because of technological advances, medical records may be electronic as opposed to being on paper. There are advantages and disadvantages to electronic records. The following are advantages:
Instant access
Remote access to up-to-date information
Simultaneous access
Decreased time to record information
Legible
Better organization
Flexible data layout
Automated checks and reminders
Increased privacy and decreased tampering, destruction, and loss due to required authorization
The following are disadvantages of electronic medical records:
Additional hardware, software, and licensing costs
Resistance to giving up paper records
Difficult data entry
Training
Computer downtime, such as unexpected failure or routine servicing
Confidentiality and security concerns, such access of information to unauthorized individuals

7. Lesson 4– Electronic Medical Records (Continued)
Disadvantages:
Additional hardware, software, and licensing costs
Resistance to giving up paper records
Difficult data entry
Training
Computer downtime, such as unexpected failure or routine servicing
Confidentiality and security concerns, such access of information to unauthorized individuals
Electronic Medical Records
Because of technological advances, medical records may be electronic as opposed to being on paper. There are advantages and disadvantages to electronic records. The following are advantages:
Instant access
Remote access to up-to-date information
Simultaneous access
Decreased time to record information
Legible
Better organization
Flexible data layout
Automated checks and reminders
Increased privacy and decreased tampering, destruction, and loss due to required authorization
The following are disadvantages of electronic medical records:
Additional hardware, software, and licensing costs
Resistance to giving up paper records
Difficult data entry
Training
Computer downtime, such as unexpected failure or routine servicing
Confidentiality and security concerns, such access of information to unauthorized individuals

8. Lesson 4– Confidentiality of Electronic Records
Limit individuals who have access to records by using passwords, fingerprints, voice recognition, and eye patterns.
Require codes to access specific information.
Place monitors in areas where others cannot see the screen.
Do not leave monitors unattended while confidential information is on the screen.
Do not send confidential information by .
Back up data.
Constantly monitor and evaluate the use of electronic medical records.
Confidentiality of Electronic Records
To ensure that electronic medical records are confidential and secure, the following protective measures should be taken:
Limit individuals who have access to records by using passwords, fingerprints, voice recognition, and eye patterns.
Require codes to access specific information.
Place monitors in areas where others cannot see the screen.
Do not leave monitors unattended while confidential information is on the screen.
Do not send confidential information by .
Back up data.
Constantly monitor and evaluate the use of electronic medical records.

9. Lesson 4– Printers and Copiers
Do not leave printers unattended while printing confidential information.
Do not print confidential information on printers that are shared by unauthorized individuals.
Do not print confidential information on wrong printers.
Make sure to collect printouts of confidential information from printers.
Do not throw unneeded printouts of confidential information in trash cans. Instead, these should be shredded.
Printers and Copiers
In addition to electronic medical records, protective measures should be taken in regard to other technology tools. These tools include printers, copiers, fax machines, and telephones.
Printers:
Do not leave printers unattended while printing confidential information.
Do not print confidential information on printers that are shared by unauthorized individuals.
Do not print confidential information on wrong printers.
Make sure to collect printouts of confidential information from printers.
Do not throw unneeded printouts of confidential information in trash cans. Instead, these should be shredded.
Copiers:
Do not copy confidential information if unauthorized individuals are in the area and can see the information.
Do not leave copiers unattended while copying confidential information.
If a paper jam occurs, be sure to remove the copies that caused the jam from the copier.
Make sure to collect all copies of confidential information as well as the original from the copier.
Do not throw unneeded copies of confidential information in trash cans. Instead, these should be shredded.

10. Lesson 4– Printers and Copiers (Continued)
Do not copy confidential information if unauthorized individuals are in the area and can see the information.
Do not leave copiers unattended while copying confidential information.
If a paper jam occurs, be sure to remove the copies that caused the jam from the copier.
Make sure to collect all copies of confidential information as well as the original from the copier.
Do not throw unneeded copies of confidential information in trash cans. Instead, these should be shredded.
Printers and Copiers
In addition to electronic medical records, protective measures should be taken in regard to other technology tools. These tools include printers, copiers, fax machines, and telephones.
Printers:
Do not leave printers unattended while printing confidential information.
Do not print confidential information on printers that are shared by unauthorized individuals.
Do not print confidential information on wrong printers.
Make sure to collect printouts of confidential information from printers.
Do not throw unneeded printouts of confidential information in trash cans. Instead, these should be shredded.
Copiers:
Do not copy confidential information if unauthorized individuals are in the area and can see the information.
Do not leave copiers unattended while copying confidential information.
If a paper jam occurs, be sure to remove the copies that caused the jam from the copier.
Make sure to collect all copies of confidential information as well as the original from the copier.
Do not throw unneeded copies of confidential information in trash cans. Instead, these should be shredded.

11. Lesson 4– Fax Machines and Telephones
Contact the receiver and verify the fax number before faxing confidential information.
Do not fax confidential information to unauthorized individuals.
Attach a cover sheet that contains a confidentiality statement.
Do not fax confidential information if unauthorized individuals are in the area and can see the information.
Do not leave fax machines unattended while faxing confidential information.
Do not throw unneeded faxes of confidential information in trash cans. Instead, this should be shredded.
Fax Machines and Telephones
Protective measures should also be taken in regard to fax machines and telephones.
Fax machines:
Contact the receiver and verify the fax number of the receiving location before faxing confidential information.
Do not fax confidential information to unauthorized individuals.
Attach a cover sheet that contains a confidentiality statement.
Do not fax confidential information if unauthorized individuals are in the area and can see the information.
Do not leave fax machines unattended while faxing confidential information.
Make sure to collect confidential information from fax machines.
Do not throw unneeded faxes of confidential information in trash cans. Instead, this should be shredded.
Contact the receiver after faxing confidential information.
Telephones:
Do not use patients’ names if unauthorized individuals are in the area and can overhear.
When leaving messages, simply ask patients to return the call. Do not speak about any confidential information.

12. Lesson 4– Fax Machines and Telephones (Continued)
Do not use patients’ names if unauthorized individuals are in the area and can overhear.
When leaving messages, simply ask patients to return the call. Do not speak about any confidential information.
Fax Machines and Telephones
Protective measures should also be taken in regard to fax machines and telephones.
Fax machines:
Contact the receiver and verify the fax number of the receiving location before faxing confidential information.
Do not fax confidential information to unauthorized individuals.
Attach a cover sheet that contains a confidentiality statement.
Do not fax confidential information if unauthorized individuals are in the area and can see the information.
Do not leave fax machines unattended while faxing confidential information.
Make sure to collect confidential information from fax machines.
Do not throw unneeded faxes of confidential information in trash cans. Instead, this should be shredded.
Contact the receiver after faxing confidential information.
Telephones:
Do not use patients’ names if unauthorized individuals are in the area and can overhear.
When leaving messages, simply ask patients to return the call. Do not speak about any confidential information.