Agenda: Seminar 6
• Discussion of Unit 4 Project
• Chapter 9 Material
• Remember to take the Unit 6 Quiz!
If you
complete it quickly, use your extra time to
check your answers!
Medical Law and Ethics, Third Edition
Bonnie F. Fremgen
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Unit 4 Project
•
•
•
•
Overall, answers need to be longer. A one-sentence
answer is probably not going to answer the question
completely. The exception is where the question simply
asks for a list of items (like question 2 from the unit 4
project).
RESEARCH! Many of the answers can be found in the
book. You may consult the index in the back of the book to
help find the answer.
Spelling/Grammar: Use your spell-checker and read it
before submitting it to check for grammar issues. Seek help
from the Kaplan Writing Center.
Make sure your answer addresses the question asked.
Medical Law and Ethics, Third Edition
Bonnie F. Fremgen
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Examples of Project Answers
•
•
•
Question: What is the difference between civil law and criminal
law?
Answer 1: Civil law is generally for the civilians and criminal law is for the criminals.
It would be agains the law for civilians to commit crimes. That is why they are
called cibil and criminal laws.
Answer 2: There are many differences between civil and criminal law, including
parties involved, purposes, and standards of proof. Civil law generally concerns
disputes between two private parties. (Fremgen, pg. 32) The purpose of civil law
is to make a damaged party whole by award of money damages, injunctions, or
other court-ordered relief. (Fremgen, pg. 32) There are many types of civil
actions, such as class action lawsuits, contracts, and torts. (Fremgen, pg. 32-38)
In contrast, criminal law serves a very different purpose. Criminal laws protect the
public by punishing socially intolerable acts. (Fremgen, pg. 38) In a criminal case,
the government prosecutes accused criminals, resulting in fines, imprisonment, or
both if the accused is found guilty. (Fremgen, pg. 38-39) Since accused criminal
cases are deprived of liberty if found guilty, the defendant must be proven guilty
beyond a reasonable doubt, whereas a defendant must be proven liable by a
preponderance of the evidence standard in a civil case. (Fremgen, pg. 44)
Medical Law and Ethics, Third Edition
Bonnie F. Fremgen
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Medical Law and Ethics
Chapter 9
The Medical Record
Medical Law and Ethics, Third Edition
Bonnie F. Fremgen
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
The Medical Record
•
•
All written documentation relating to patient
Includes
–
–
–
•
•
Past history
Current diagnosis and treatment
Correspondence relating to patient
Is a legal document
May be subpoenaed
Medical Law and Ethics, Third Edition
Bonnie F. Fremgen
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
What is the purpose of the medical
record?
Medical Law and Ethics, Third Edition
Bonnie F. Fremgen
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
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
Medical Law and Ethics, Third Edition
Bonnie F. Fremgen
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
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
Medical Law and Ethics, Third Edition
Bonnie F. Fremgen
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Figure 9.2
Example of SOAP Charting
Medical Law and Ethics, Third Edition
Bonnie F. Fremgen
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Two Common Forms of Charting
•
•
POMR: Problem-Oriented Medical Record
includes chronological record of each visit
SOAP: subjective, objective, assessment, plan
–
–
–
–
Subjective statements of patient
Objective data such as lab reports, vital signs
Assessment or diagnosis
Plan of treatment
Medical Law and Ethics, Third Edition
Bonnie F. Fremgen
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
What action should be taken if you
identify an error in a patient’s
medical record?
Medical Law and Ethics, Third Edition
Bonnie F. Fremgen
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Corrections and Alterations
•
•
•
•
•
Draw one line through error
Write correction above error
Date and initial change
Do not erase or use correction fluid
Falsification of medical record is grounds for
criminal indictment
Medical Law and Ethics, Third Edition
Bonnie F. Fremgen
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Figure 9.3
Example of Corrected Chart Notation
Medical Law and Ethics, Third Edition
Bonnie F. Fremgen
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
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
Medical Law and Ethics, Third Edition
Bonnie F. Fremgen
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
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”
Medical Law and Ethics, Third Edition
Bonnie F. Fremgen
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
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
Medical Law and Ethics, Third Edition
Bonnie F. Fremgen
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Ownership
•
•
Physicians or owners of health care facility own
the medical record
Patients have legal right of “privileged
communication” and access to records
Medical Law and Ethics, Third Edition
Bonnie F. Fremgen
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Ownership (continued)
•
•
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
Medical Law and Ethics, Third Edition
Bonnie F. Fremgen
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Release of Information
•
•
Never send entire medical chart unless it is
requested
Do not send original
Medical Law and Ethics, Third Edition
Bonnie F. Fremgen
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Release of Information (continued)
•
•
Record may not be released to patient without
physician’s permission
Patient must sign release form for information
to be sent to insurance company
Medical Law and Ethics, Third Edition
Bonnie F. Fremgen
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Privacy Act of 1974
•
•
•
Agency may maintain only information relevant
to its authorized purpose
Citizens have right to gain access to records
and to copy records if necessary
Applies only to federal agencies
and government contractors
Medical Law and Ethics, Third Edition
Bonnie F. Fremgen
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
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
Medical Law and Ethics, Third Edition
Bonnie F. Fremgen
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
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
Medical Law and Ethics, Third Edition
Bonnie F. Fremgen
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
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
Medical Law and Ethics, Third Edition
Bonnie F. Fremgen
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Storage
•
•
•
•
Current records usually kept within physician's
office
May rent storage space
May be placed on microfilm
Kept in fire-proof, locked area
Medical Law and Ethics, Third Edition
Bonnie F. Fremgen
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Computerized Medical Records
•
•
•
Data on patient records can be created,
modified, authenticated, stored, and retrieved
by computer
Special safety measures should be taken to
establish personal identification and user
verification codes for access to records
Should be accessed on need-to-know basis
Medical Law and Ethics, Third Edition
Bonnie F. Fremgen
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
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
Medical Law and Ethics, Third Edition
Bonnie F. Fremgen
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
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
Medical Law and Ethics, Third Edition
Bonnie F. Fremgen
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
•
•
What steps should be taken to ensure that the
medical record is maintained as a legal
document?
Give an example of when legal regulations and
ethical standards come into conflict with
respect to medical records.
Medical Law and Ethics, Third Edition
Bonnie F. Fremgen
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.