PERSONAL MEDICAL INFORMATION
The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care.
The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.
An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.
The traditional medical record for inpatient care can include admission notes, on-service notes, progress notes (SOAP notes), preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes.
Personal health records combine many of the above features with portability, thus allowing a patient to share medical records across providers and health care systems.[7]
Electronic medical records could also be studied to quantify disease burdens – such as the number of deaths from antimicrobial resistance[8] – or help identify causes of, factors of and contributors to diseases,[9][10] especially when combined with genome-wide association studies.[11][12]
For such purposes, electronic medical records could potentially be made available in securely anonymized or pseudonymized[13] forms to ensure patients' privacy is maintained.[14][12][15][16]
Administrative issues
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A ward clerk in the Menn Hospital, Colorado
Medical records are legal documents that can be used as evidence via a subpoena duces tecum,[21] and are thus subject to the laws of the country/state in which they are produced.
As such, there is great variability in rules governing production, ownership, accessibility, and destruction.
There is some controversy regarding proof verifying the facts, or absence of facts in the record, apart from the medical record itself.
In 2009, Congress authorized and funded legislation known as the Health Information Technology for Economic and Clinical Health Act[22] to stimulate the conversion of paper medical records into electronic charts.
While many hospitals and doctor's offices have since done this successfully, electronic health vendors' proprietary systems are sometimes incompatible.[23]
US law and customs
In the United States, the data contained within the medical record belongs to the patient, whereas the physical form the data takes belongs to the entity responsible for maintaining the record[24] per the Health Insurance Portability and Accountability Act.[25]
Patients have the right to ensure that the information contained in their record is accurate, and can petition their health care provider to amend factually incorrect information in their records.[21][26]
There is no consensus regarding medical record ownership in the United States.
Factors complicating questions of ownership include the form and source of the information, custody of the information, contract rights, and variation in state law.[27]
There is no federal law regarding ownership of medical records.
HIPAA gives patients the right to access and amend their own records, but it has no language regarding ownership of the records.[28]
Twenty-eight states and Washington, D.C., have no laws that define ownership of medical records.
Twenty-one states have laws stating that the providers are the owners of the records.
Only one state, New Hampshire, has a law ascribing ownership of medical records to the patient.[29]
In the United States, the most basic rules governing access to a medical record dictate that only the patient and the health-care providers directly involved in delivering care have the right to view the record.
The patient, however, may grant consent for any person or entity to evaluate the record.
The full rules regarding access and security for medical records are set forth under the guidelines of the Health Insurance Portability and Accountability Act (HIPAA).
The rules become more complicated in special situations.
A 2018 study found discrepancies in how major hospitals handle record requests, with forms displaying limited information relative to phone conversations.[37]
The federal Health Insurance Portability and Accessibility Act (HIPAA) addresses the issue of privacy by providing medical information handling guidelines.[46]
Not only is it bound by the Code of Ethics of its profession (in the case of doctors and nurses), but also by the legislation on data protection and criminal law.
Professional secrecy applies to practitioners, psychologists, nursing, physiotherapists, occupational therapists, nursing assistants, chiropodists, and administrative personnel, as well as auxiliary hospital staff.
The maintenance of the confidentiality and privacy of patients implies first of all in the medical history, which must be adequately guarded, remaining accessible only to the authorized personnel.
However, the precepts of privacy must be observed in all fields of hospital life: privacy at the time of the conduct of the anamnesis and physical exploration, the privacy at the time of the information to the relatives, the conversations between healthcare providers in the corridors, maintenance of adequate patient data collection in hospital nursing controls (planks, slates), telephone conversations, open intercoms etc.
Medical records are legal documents that can be used as evidence via a subpoena duces tecum,[21] and are thus subject to the laws of the country/state in which they are produced.
As such, there is great variability in rules governing production, ownership, accessibility, and destruction. There is some controversy regarding proof verifying the facts, or absence of facts in the record, apart from the medical record itself.
In 2009, Congress authorized and funded legislation known as the Health Information Technology for Economic and Clinical Health Act[22] to stimulate the conversion of paper medical records into electronic charts.
While many hospitals and doctor's offices have since done this successfully, electronic health vendors' proprietary systems are sometimes incompatible.[23]
In the United States, written records must be marked with the date and time and scribed with indelible pens without use of corrective paper. Errors in the record should be struck out with a single line (so that the initial entry remains legible) and initialed by the author.[21] Orders and notes must be signed by the author. Electronic versions require an electronic signature.