Question

The Health Record STUDY QUESTIONS 1. List the type of 2. Discuss the diffe she type of information contained in a health record. e the difference between ownership of a health record and 3. A patient request ownership of other property. natient requests his x-rays to take home and show to the family. Role-play how you would handle this matter. Bivacy means many different things in a medical setting. Distin- ich between the patient's right to physical privacy and privacy of privileged communication. medical assistant, privileged communication includes your knowledge of the patient. Your office has a famous celebrity as a patient. A well-known newspaper reporter calls and asks you to go to lunch with her. How will you handle this matter? 6. Your office has a strict policy with regard to release of information in health records, and despite a state statute allowing patients access to their records, the physicians you work for will not give patients their records. An obnoxious attorney storms into the office and demands access to your files. The patient has signed a release form. You are at the front desk and the office is full of patients. What do you do? 7. Your office has a relaxed policy with regard to the release of infor- mation in health records. A patient asks to see his record. You know that there is information in the record regarding telephone calls from the patient's relatives that would interfere with the fam- ily relationship. The physician is away for a week. How would you handle the matter? 8. A health record has been subpoenaed and a court order accompa- nies it. The physician has removed important parts of the record. You know that this information is missing. The office sends you to court as the keeper of the record. You must testify about the completeness of the record. What are you going to say? 9. There is an error in a health record that has been subpoenaed. This is a good faith error and should be corrected. It has to do with the information the plaintiff is interested in and could be damaging to the defendant-physician if changed, but also damaging if unchanged. The physician asks you to blot out the error, write in the correct infor- mation and put the paper, with surrounding papers, through the copy machine. What do you do?

Answer 1

1. Types of information in a health record can be broadly classified as clinical and administrative.

Patient’s clinical information includes:

• Medical history and pertinent family history.
• Physical examination report.
• Diagnostic and therapeutic orders.
• Clinical observations.
• Reports and results of diagnostic and therapeutic procedures.
• Consultation report.
• Discharge summary/transfer records/autopsy report.
• Final instructions upon discharge.

Patient’s administrative information includes:

• Demographic information including patient’s full name, medical record number, address, DOB, gender, date and time of admission/visit, type of admission etc.
• Financial information includes insurance information, social security number etc.
• Consent to treatment.
• Authorizations including advance directives, DNR, DNI etc.
• Acknowledgements of patient’s rights.

2. The medical record belongs to the physician and the healthcare facility where it was created and they are the owners but the information in the medical record is owned by the patient. Patients are allowed only a copy of their medical record, but not the original document with no right to possession, disposition, and destruction whereas in the case of ownership of any other property, the owner has the right to possession, disposition, and destruction. That means the patient is the owner of the information in a medical record without full ownership rights.