Medical Records

What is the purpose of medical records?

• To provide a written account of the health care for a patient

• To provide conformation of a patients appointments.

• To provide a documentation of medical services for insurance purposes.

• To obtain consent from a patient prior to surgery.

• To obtain consent from a patient prior to treatment.

What rights do patients have regarding their medical records?

• None

• To view and make copies

• Rights to have records destroyed

• Rights to view only

What is a disadvantages of paper records?

• They are old and out of date

• They can be used by only one person at a time.

• May be easily lost or damaged

• They take a long time to mail.

• May take hours or days to retrieve from storage

What are the advantages of EMRs (AKA: EPR, EHR, CPRs)?

• May become lost or damaged

• They cannot be lost damaged because backup copies are available

• Can be accessed by one individual at a time

• Can be access at the same time by multiple individuals

• Take only seconds to retrieve ( available in emergencies)

A medical record is a legal document that may be ordered by the court to be available during a malpractice case.

• True

• False

Under Federal Regulations, HIPAA requires that medical records be kept...

• accurate

• confidential

• stored

• available

The medical record must include information about patient care such as

• admitting diagnosis.

• physician examination report and documentation of complications.

• discharge summary and follow-up care.

• all of the answers are true

To protect patient confidentiality, medical records can be released

• to an attorney.

• to a judge.

• to the patient's family members.

• only with the patient's written consent.

• to insurance companies.

Computerized medical records

• pose problems of confidentiality.

• make record maintenance and retrieval more efficient.

• should be accessed on a need-to-know basis.

• all of the above.

Physicians who wish to disclose confidential medical record information should

• first discuss it with the patient's family.

• discuss it with the patient first.

• discuss the risks involved with his or her lawyer.

• first discuss the problem with the patient's contact person.

• have written consent from the patient.