Medical Care Law

Chapter 7 - Medical Records

Highlights

Improper medical records can subject health care practitioners to civil and criminal liability.

Medical records must meet federal standards for documentation.

Even informal medical encounters should be documented.

Patient confidentiality must be respected when releasing medical records.

Medical records must never be altered or fabricated.

Introduction

A Historical Perspective

Legal Uses Of Medical Records

Medical Malpractice Litigation

Medical Records as a Plaintiff's Weapon

Defensible Records

Administrative Review of Records

Criminal Discovery

Quality Assurance and Accreditation Review of Records

Medical Office And Clinic Records

Basic Patient Information

Team and Managed Care

Maintaining the Records

Readability

Altered Records

Protecting Records

Retention of Records

Statutory Requirements on Recordkeeping

Destroying Records

Telephone Encounters

Off-Chart Records

Releasing Medical Records

Authorizing Release of Medical Information

Preventing Unauthorized Release

Selling Medical Records

Pediatric Records

Acute Illness Observation Scale

Recording Physical Growth and Development

Recording Neuromuscular Development

Hospital Medical Records

Electronic Medical Records

References

Suggested Readings

Exhibit 7-1 - P.L. Mccarthy's Technique For Evaluating Pediatric Patients