Medical Records and Informed Consent

Medical Records can prevail over a patient’s recollection of events during a trial. When there is no documentation, it is assumed nothing was done.

Stop and look at page 196 for information that must be recorded in a patient’s record.

Five Cs of Charting

Be Concise

Complete

Be Clear

Correct

Chronologically ordered**They should never include inappropriate personal judgments or observations or attempts at humor.

IF: a health care facility routinely photographs patients to

document care, a special consent form should be signed stating that:

The patient understands that the images may be taken to document care.

The patient understands that ownership rights to the images will be retained by the health care facility, but that he or she will be allowed to view or obtain copies.

Images of the patient will not be released and/or used outside the health care facility without written authorization from the patient or his or her legal representative.

If

the images will be used for teaching or publicity, a separate consent form should be used.

Errors Do not erase or white out—draw one line through the error and write correct notation above or in margin and initial it.

Do not write “error” as your book says as this has been misconstrued in a court of law as an error in patient care.

You can correct the error by putting

LE (late entry), and put the time and date of the entry you are correcting. Then the entry can say” Clarification of notation on date ____ TIME____. Now note the correct information and sign the notation.

Who owns the medical Record?The facility owns the actual records. The Patient owns the information in the records. However, under the doctrine of professional discretion, courts have held that in some cases, patients treated for mental or emotional conditions may be harmed by seeing their own records. The patient cannot get a copy of an incident report without a subpoena. If records are requested by subpoena for court, the patient should be notified in writing.

As a protection in the event of litigation, records should be kept until the statute of limitations period has elapsed, which generally ranges from two to seven years. In some cases minor’s records have to be kept for a specified length of time after they reach legal age. Most physicians retain records indefinitely.

So………….your physician is being sued. You are the person responsible for the medical records in your office. Your physician has received a subpoena for a patient’s medical

record. Look at page 202 for tips you should follow.

Look at page 202 for rules for authorizations for the release of medical records.

The doctrine of informed consent is the legal basis for informed consent and is usually outlined in a state’s medical practice acts.

http://kbml.ky.gov/board/Pages/Kentucky-Medical-Practice-Act-Statutes-and-Regulations.aspx

Informed consent implies that the patient understands:

Modes of treatment Why the treatment is necessary Risks involved in treatment Available alternative modes of treatment Risks of alternative modes of treatment Risks involved if treatment is refused

Adults of sound mind are usually able to give informed consent. Who cannot give informed consent?1. Minors, persons under the age of

majority except?? Page 204 and 2052. Persons who are mentally incompetent.

For whatever reason3. Persons who speak limited or no English

When consent is unnecessary: In emergency situations, when the patient is in immediate danger, the physician is not expected to obtain consent before proceeding with treatment. All 50 states have passed Good Samaritan Acts.

http://chfs.ky.gov/NR/rdonlyres/B954EF52-7BE0-440A-84B6-3C2C8B8709E4/0/KentuckyGoodSamLaw.pdf

Technology Don’t leave confidential papers in the copier Do not discard copies in a shared trash container?

Don’t leave papers in a paper jam.

Always verify phone number of the receiving location.

Never fax to an unauthorized person.Do not locate computer monitors in an area where others can see the screen.Do not leave computer monitor unattended. Do not send confidential patient information via e-mail.