This is an update to the blog – The Legal Health Record – Its Components, Significance & Some Considerations
The legal health record constitutes the medical record set of a patient containing relevant information obtained from or about the patient. It may include audio and video recordings, as well as the information provided by third parties such as relatives. All medical data collected regarding the patient, processed and stored in manual and electronic format is included in the health record.
Medical records and medical record review have a unique legal standing. While they are the providers’ business records, they are also highly confidential and typically require the patient’s permission before they can be shared with another entity. Most US states have passed medical privacy laws that restrict the sharing of medical information without the patient’s consent. Exceptions are when the medical record is needed at the discovery stage of a lawsuit such as when the patient has filed a legal claim based on that medical data.
Medical Records and Their Legal Use
Medical records are required for medical record analysis to extract evidence in cases such as the following.
- Personal injury
- Workers’ compensation
- Medical malpractice
- Insurance cases
- Product liability
Considering the legal aspects of medical records,
- The best, reliable medical evidence needs to be used at trial, and that too the original records, not photocopies.
- Medical reimbursement is provided based on the medical documentation available. If there is no documentation regarding a service provided, there will be no reimbursement either.
- Medical records that are lost or destroyed due to intentional acts of negligence could lead to legal claims against the healthcare provider.
- Medical records must be kept for a certain period of time and this retention time varies with each state. In general, healthcare facilities are required to follow the Medicare Condition of Participation Guidelines. Hospitals must retain medical records in their original form for a period of five years. If the state doesn’t have any specific regulations, the records may have to be retained infinitely or for a minimum of 10 years or 25 years, preferably the latter, after the last contact with the patient.
- The time that a claimant has to file a lawsuit of negligence against practitioners may vary from one state to another. For minors, it usually ends when they turn 21.
- OSHA mandates employers to maintain the medical records of employees (who have been exposed to toxic substances or other harmful agents) for 30 years.
- Facilities certified as a comprehensive outpatient rehabilitation facility or CORF must keep the medical records for 5 years after the patient is discharged.
- Physicians’ handwritten notes are part of the legal medical record. Referral forms, phone conversations, data sheets and so on are all part of the medical chart and can be subpoenaed in a legal proceeding.
- Any additions, deletions or modifications made in the medical records have to be carefully done. If the healthcare facility maintains paper records, the provider making the correction must include his/her name alongside the date of correction. This would clarify that the modified entry was made on that particular date.
- While continuity of care is the main reason to maintain medical records, they may be necessary if for instance, the patient files a claim after a workplace injury or some other accident. Good medical records are vital for defending a complaint or clinical negligence claim because they provide clear insight into the clinical judgment exercised at that time.
Good and accurate medical record keeping is valuable when responding to and defending against an insurance claim. In fact, a complete medical record set and other records may be the only defence available to the healthcare provider in case of a medical negligence lawsuit. Medical record review specialists would recommend that all key details of patient contact should be summarized in the medical chart. Apart from the relevant clinical findings, the medical records should also reflect the decisions made and agreed actions, and the persons making and agreeing to these decisions. Information regarding the medications administered to the patients, treatments, investigation, the progress made by the patient, people making the record and so on must be included to ensure legal value for the medical record.