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Information Management: The Medical Record As A Legal Document

3671 words - 15 pages

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 the patient’s care (Pozgar 2007). These records must be complete and accurate in order to meet any and all expectations set forth by both the state and the hospital in which the patient is seeking care. These records make up part of the hospital’s information system. Said information systems must be readily accessible and will include all necessary information including, human resources, financial information, and most importantly medical records. By updating a patient’s record and making it readily available to all health care providers, the information system allows a flow of information from one department to the other; without risking the loss of paper notes on the way (Pozgar 2007).
A medical record has many essential roles within any health care organization; these records contain a plethora of medical information for the patient. Medical records are required to contain correct and precise information such as patient demographics (address, phone number, and age), any consent and authorization forms that the patient signed for treatment, family and patient medical history, and any diagnosis that is made using the patient’s medical history and their current health complaints. All information that pertains to the...

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