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A health care provider or health plan may only send copies of your records to another provider or health plan if it is necessary for processing or payment, or with your permission. Impersonal documents were used for research purposes because the patient`s identity is not revealed. Although the patient`s identity is not revealed, the research team is aware of the patient`s records and raises concerns about the confidentiality of the information. In the past, such research was exempt from ethics review and researchers were not required to obtain patient consent before using their records. Recently, there has been a need to regulate the use of medical records in research and to effectively restrict the way this type of research is conducted. Ethics review is required for the use of patient data. However, this is not tracked across India. Categorizing record types can help understand similarities and differences, and help organizations develop policies for each record type. Some types of records are found in both the designated record and the statutory health record, while others are specific to the specified record. The following table provides examples of different types of records and shows the similarities and differences between the two sets of information. Medical records are usually summoned to court in the following cases: A major point of contention between the patient and the attending hospital concerns the ownership of medical records.

For the most part, medical records belong to hospitals and hospitals are responsible for maintaining them properly. Hospitals and doctors need to be careful with medical records, as they can be stolen, manipulated, and abused for the wrong reasons by interested parties. Therefore, records must be kept in a secure location. The hospital has the primary responsibility for maintaining and creating patient records at the request of the patient or the appropriate judicial authorities. However, it is the primary duty of the attending physician to ensure that all documents relating to administration are correctly drafted and signed. An unsigned medical record has no legal validity. The patient or his/her legal heirs may request copies of treatment records, which must be submitted within 72 hours. Hospitals may charge a reasonable amount for administrative purposes, including photocopies of documents.

Failure to provide medical records to patients upon appropriate request constitutes a lack of service and negligence. In addition, the type of medium on which information is stored is also expanding. Source recordings can include diagnostic images, videos, voice files, and emails. The organization must determine which of these data elements, electronically structured documents, images, audio files, and video files should be included. Health organizations can take the following basic steps to eliminate confusion about the legal health record and the overall record, as well as the disclosure of information from both: There is a school of thought that these external records cannot and should not be part of the legal health record because they cannot confirm how they were originally created. Their inclusion in the legal health record may result in implied liability for inaccuracies contained in external records. This practice review compiles and updates the guidelines of four previously published practice descriptions to provide an overview of the objectives of the established dataset and the legal health record, and to assist organizations in determining what information should be included in each. It also includes guidelines for the disclosure of medical records of the sets. The four original exercise descriptions are listed in the “Sources” section at the end of this exercise summary. However, including external documents as part of the designated document and providing them in all relevant disclosures, including disclosures in response to a subpoena, may serve the same purpose. The organization`s legal counsel should be consulted before establishing guidelines for the inclusion of external records in the legal health record. There is no uniform definition of legal health record and defined record.

The health care organization must explicitly define both in a multidisciplinary team approach. For example, medical staff should provide guidance to ensure that the need for patient care is met for immediate, long-term and research purposes.† * There are two views on whether external records mentioned for patient care are part of the legal health record. One view is that they should be if they were relied upon to make care decisions. The other view is that while they are part of the established dataset and available for patient care and disclosure, they should not be because the organization is unable to confirm how the external datasets were originally created. Organizations should consult with their lawyers to assess the risks and benefits of both approaches. Copies of PSRs owned by the patient, retained and completed by the individual, but provided to one or more health care providers should be considered part of the statutory health record. These records are then used by healthcare providers to provide patient care services, verify patient data, or document observations, actions, or instructions. This includes “follow-up” records owned, managed and completed by patients, such as medication tracking records and blood glucose and insulin monitoring records. Examples of administrative data: Authorization forms for information sharing Correspondence regarding requests for documents Event history/audit trails Clinical protocols/pathways, practice guidelines and other sources of knowledge that do not integrate patient data Patient-identifying claims that are reviewed for quality assurance or usage management Death certificates Patient identifiers (e.g. Medical Record Number, Biometrics) Purpose: This policy identifies [the organization`s] health record for business and legal purposes and to ensure that the integrity of the health record is maintained so that it can meet operational and legal requirements. Questions to ask include whether the source system can print or download to a CD, how the requester accesses it, and whether it is in an understandable format. The legal health record elements and defined dataset must be reproducible in an accessible format.

See Appendix B for a comparison of the statutory health record with the planned dataset. The issue of medical record retention has been addressed in the Medical Council of India Regulations 2002 guidelines, which answer many questions about medical records. The important issues raised are that some records must be given to the patient by law. The discharge summary, reference notes and summary of death in case of natural death are important documents for the patient. Therefore, these must be given free of charge for everyone, including patients who go against medical advice. The hospital bill cannot be linked to these sensitive documents that are necessary for subsequent patient care. Therefore, the above documents cannot be legally refused, even if the hospital bill has not been paid. As mentioned earlier, medical records are important evidence of medical negligence and injury claims and therefore must be carefully drafted and retained. During the review of a medical record, the medical record must contain clear, accurate, chronological, consistent and complete details about patient care.

Each health care provider must ensure that the patient`s record remains the best evidence for medico-legal purposes, while providing all the medical information necessary to ensure that the patient receives the best treatment and care. [The organization`s] policy is to maintain medical records that are not compromised and to meet the operational and legal needs of [the organization]. The request for a medical record by the patient or their authorized companion must be confirmed and the documents issued within 72 hours (section 1.3.2). The confidentiality rule gives you, with some exceptions, the right to access, review and obtain a copy of your medical and billing records maintained by health plans and health care providers covered by the confidentiality rule. However, a supplier may charge the reasonable cost of copying and sending documents. The provider cannot charge you a fee for searching or retrieving your documents. Policy: [The organization`s] policy is to create and maintain health records that meet the operational and legal needs of [the organization] in addition to its primary goal of clinical and patient care. The business record generated by or for a health care organization. It is the document that is communicated upon receipt of an application.

The legal health record is the officially declared record of health services provided to an individual by a provider. Equally important, organizations must identify information that is not included in the health record or the statutory aggregate record. Data such as audit trails, metadata, and psychotherapy notes are not included in the definitions of these records. See Appendix D for an example of a list of items that do not fall within the legislated health record and the specified record. An additional component of the legal business case, as defined by the organization.

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