Question

Read Chapter 9, and discuss the following cases to the best of your abilities:

THE CASE OF ANESHA AND THE LOST MEDICAL RECORD

Anesha’s 15-year-old daughter, Robin, is experiencing abdominal pain when exercising during her gym class. After reviewing the results of several tests, Robin’s pediatrician still cannot determine the cause of Robin’s abdominal pains. He asks Anesha if she had any obstetrical problems when she was pregnant with Robin. Anesha had just read a report in a national newspaper discussing the use of a hormonal treatment to control bleeding that was used on expectant mothers at about the time that Anesha was pregnant with Robin. The report stated that female children could develop serious uterine problems, including cancer, during their adolescence if their mothers were given a particular hormone during their pregnancy that was in use 15 to 20 years ago. The report went on to state that male children were unaffected. Anesha recalled that her obstetrician, Dr. C., had given her that particular hormone medication to control bleeding during her pregnancy with Robin and also when she was expecting Robin’s brother, Sam. Anesha wrote Dr. C. to request her medical record and ask if the doctor had prescribed the hormone treatment during her pregnancy. She received a letter stating that Dr. C. could not recall what he prescribed 15 or 16 years previously. The letter also stated that all his records were destroyed in a fire five years ago (Fremgen, 2016, p. 220).

What should Anesha tell Robin’s pediatrician?

What does Robin need to know about her potential for a serious uterine diagnosis?

How could this situation have been prevented?

What is the significance of the medical record for the physician? For the healthcare professional? For the patient?

Who owns the medical chart?

Important Notice: Your professor will consider these characteristics when assessing the quality and level of student participation.

Submit initial post(s) early in the session and subsequent responses to the posts of other learners at timely intervals throughout the duration of the session. The goal is to have a dynamic discussion around the topic that lasts throughout the entire session.

Your original post should be within a range of 75-150 words. If a post does not meet the minimum word count of 75, your professor will not count it toward your grade.

Your subsequent contributions responding to a classmate should have 50 to 75 words.

Book: Medical Law and Ethics by Bonnie F. Fremgen - Fifth Edition

Answer 1

What should Anesha tell Robin’s pediatrician?

I was on hormonal treatment to control bleeding when I was pregnant with Robin. Maybe the unknown hormonal medicine is the cause of abdominal pain. But I couldn't find that the medication name. May this cause Robin's present problems.

What does Robin need to know about her potential for a serious uterine diagnosis?

Uterine problem is a condition is associated with the female uterus. There are several uterine problems which lead to abdominal pain and bleeding. Endometriosis is a condition where the lining of the uterus tissue grows outside. The fibroid is a noncancerous growth develop inside the uterus. Menstrual irregularities, Amenorrhea also lead to abdominal pain. Sometimes hormonal imbalances also lead in abdominal pain. Serious condition like cancer, the pelvic inflammatory disease can also be the potential reason for abdominal pain.

What is the significance of the medical record for the physician? For the healthcare professional? For the patient?

The medical record is an important document for the physician to track the previous history and to get the required health information. It helps the physician to compare the previous data with the current examination. It provides clues for the Clinical diagnosis of the physician. For the healthcare professional, the Medical record is a guideline which provides information about the patient, clinical notes, nurses documentation, and other lab reports. It also acts as a legal document which improves the patient safety and quality. Patients have the rights to own the medical record under the Data Protection Act. It helps the patient to get continuity of care.

Who owns the medical chart?

The physician who created the medical record owns the medical chart. It is a medicolegal document maintained by the physician and present in the Physician's office. But the patient has the rights to own the copy of the medical record.