Information Management: The Medical Record as a Legal Document

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Recommended: Patient safety in hospital setting

In order for hospitals and other health care facilities to prevent the thousands of deaths and injuries that occur every year due to medical errors; health care systems were required to implement new record keeping technology. This technology has made patient information and treatment accessible to all who needed to see it. This is especially important when a patient has more than one attending physician and their care relies on each doctor knowing what the other one has done, serving as the prime communication tool between doctors. If organizations do not centralize their technology and essentially their patient databases, the potential for duplicate work or inefficient patient care can exponentially increase. These high tech medical records can help protect physicians and hospitals alike against any lawsuits that may be filed on behalf of their patients. By correctly and thoroughly documenting all symptoms, illnesses, treatments, medication dosages, and diagnosis’ the doctor and health care providers can effectively prove what actions were taken with the patient, communicate with third party billers, and even use the gathered information for teaching purposes. Keeping a precise record of a patient’s medical treatment makes a large difference in many aspects of health care; especially when a negligence tort or claim is filed against the hospital and/or a doctor.

Hospitals are required to keep a record for each patient in accordance with the hospital’s accepted professional standards. Each state has laws that contain certain requirements that each organization must meet within their set standards. These records are required to be maintained daily, if not more often, and should contain all pertinent information that pertains to...

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...trieved from http://www.medleague.com/Services/medical_records/detecting_tampering.htm

Debusmann,B. (2011, February 8). Most Americans favor electronic medical records:study. Retrieved from http://www.reuters.com/articles/2011/02/08/us-records-electronic-idUSTRE7174QS20110208

Jethani,J. (2004). Medical records – its importance and the relevant law. Vision 2020, IV(1), Retrieved from http://laico.org/v2020resource/files/medical_records_Jan>mar04.pdf

Kasprak,J. (2006, January 9). Patient access to medical records. Retrieved from http://www.cga.ct.gov/2006/rpt/2006-R-0599.htm

Knowlton, S. (2003, April), medical record: treatment tool or litigation device? Retrieved from http://www.findarticles.com/p/articles/mi_qa3977//is_200303/ai_n9216533

Pozgar, G. D. (2007) Legal aspects of health care administration. (10th ed.). Mississauga, Canada: Jones & Bartlett

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