Medical Records Basics
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Understand the legal obligations and duties arising from the use and retention of medical records.It may seem the term 'medical records' is easy to define and that the professional and legal obligations related to their creation, use, and retention are rather straightforward. However, it is not so simple once one considers the responsibilities mandated by the highly regulated health care industry that is creating and maintaining those records and when rights to their ownership and access are asserted. In reality, the term 'medical records' is not a one-size-fits-all definition but rather encompasses varying duties and obligations that are dependent upon the patient, their illness, and type of provider. This material will help those who create and use medical records on a regular basis understand the legal obligations and duties arising from their use and retention. It will explore what constitutes a medical record and who may assert claims to their access and ownership. A discussion on best practices will be valuable to ensure proper standards and compliance are met. Case studies will be used to further illustrate when problems may arise and how planning and training may reduce the likelihood of an adverse event occurring. It is critical that individuals and employers who regularly work with medical records understand what is necessary to meet these obligations and anticipate issues that may arise in their use.
AuthorsPatrick D. Souter, Gray Reed & McGraw LLP
• What Constitutes a Medical Record?
• The Good and Bad With Electronic Medical Records
• Confidentiality vs. Privacy vs. Security: Are They the Same?
Types of Medical Records and Their Components
• Hospital and Facility Records
• Physician and Other Clinical Records
• Ancillary Providers Records
Organization and Oversight of Medical Records
• What Constitutes an Adequate Medical Record?
• Requirements to Be Able to Attest to a Medical Record
• Best Practices in Organization and Oversight
Access and Ownership of Medical Records
• Who Owns the Medical Records?
• Who May Access the Medical Records?
• When May I Withhold Releasing Medical Records?
Let's Put It All Together
• Landmines, Trapdoors, and Other Unexpected Problems
• Case Studies