Question

The next questions are based off of an ETHICS scenario

A health record technician has brought a patient’s record to the attention of the HIM director because the technician feels there are some suspicious sections in the record where the physician did not document certain treatments or purposes for treatment which may have led to an adverse outcome suffered by the patient. The HIM director has reviewed the record and agrees with the technician that a potential adverse event may have occurred. Subsequently, the physician recognizes he should have been more specific in documenting the patient’s care. He is now asking the HIM director, who is a personal friend, to let him add additional documentation to the patient’s record, which has since been placed on legal hold.

1. Since the director is a friend of the physician and knows he should have been more specific in his documentation, should the HIM director allow the physician access to the record to add the documentation? Why or why not?

2. If the HIM director did give the physician access to the record, what ethical issues does this decision raise?

Answer 1

A healthy workplace is one when there is a professional relationship existing between anybody .One should follow the hospitals or the organization policies, rules and regulation ,protocols etc.,In healthcare industry physician are considered to be person next to God or in certain cases replaced in the place of holy spirit just because of saving life.Hence these professionals should be transparent in treatment with a clear and complete documentation.Missing important documentations which can endanger a life is said to be Medical negligence and punishable.

As a HIM director ,in order to save lives and maintain the reputation of organization ,he cannot and should not allow to add documentation. Doing so is legally punishable

If the HIM director gives the physician access to the record ,it is an act of breach of security. The ethical concerns like putting the patient under risk and causing physical and emotional trauma with financial loss.