Health Care Ethics & Medical Law: Medical Records

Some of the laws that bind the professional that works with medical records are the maintaining of patient medical information such as doctors’ orders, test results, x-rays, the prescriptions of different medications etc. Medical records must be precise, complete, and protected by a health care provider so that the Patient’s sensitive and personal information cannot be accessed by any third party. Medical records are kept by law for 7 years, and must be disposed of by a paper shredder or placed in a medical records retaining box that holds such records until a professional shredding company comes to retrieve them.

Medical records” 2 The ethical issues that a medical records professional face daily are the incomplete or falsifying records from a physician or a medical staff employee, employees faxing or discussing patient information to third parties, a patient’s chart in view at a receptionist area or nurses’ station that can be seen by others, and computers not logged off or monitors turned off when an employee leaves the terminal.

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These mistakes are in direct violation of Hippa (the Health Insurance Portability and Accountability Act).

A physician not completing a chart is also “Medical Records” 3 common mistake that should be corrected by the assisting nurse. But there will be times when these records reach the medical records department personnel and as a professional, these records should be brought to the attention of the assisting nurse or the acting physician.

When falsifying occurs, despite the reason, it should also be brought to the attention of the assisting nurse or the acting physician. As we all know, that’s the correct way of approaching something like this but in reality it would be a different story. “Medical Records” 4 When this type of problem occurs, some employees tend to hy away due to reprisal and or termination. But most of the time, when brought to the physician’s attention it’s corrected immediately. It’s the responsibility of all medical staff as well as the medical records personnel to comply with Hippa guidelines.

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The Health Insurance Portability and Accountability Act or hipaa Is a law that gives the right of privacy to individuals as young as 12 and must have a signed disclosure form from the patient to release any information to third parties. Ethical issues that may “Medical Records” 5 occur in a workplace would be employees discussing a atient’s diagnosis or treatments with each other. It could go as far as an employee discussing private information with others such as friends or family outside the workplace. This happens often in many hospitals as well as medical offices and clinical settings and can cause such problems as other patients finding out, being punished for not complying with the hipaa rules and regulations which an employee can be terminated and /or do jail time. The right thing to do is advise your coworker of the “Medical Records” 6 wrong they are doing. If it does not stop, talk to the immediate supervisor about the matter.

A patient’s medical chart holds valuable and important information and It’s very crucial that nurses as well as medical records personnel handle these charts responsibly so that this information stays private. It happens often in times of emergencies or when a medical records personnel has a heavy work load that medical charts are left open and can be seen by others. Hipaa states that medical records should be locked away when not in use. Electronic medical records (EMR) is “Medical Records” 7 the most used, safest, and most secure filing system that can store medical records for later use. These types of medical records re rarely touched by others and can only be accessed by using a password. There are also fewer errors, a decrease in paper work, and will save a company time and money. In order to avoid any discrepancies, medical staff need to log off their computers when not using them and not share their passwords with others. Finally, in order to have an efficient medical records department, personnel must have weekly meetings to address any “Medical Records” 8 misunderstandings and unwanted errors on patient medical records medical records and to answer any questions about EMR procedures, ethical policies and regulations.