Closed records are a subset of the designated record set, subject to a patient’s right to request access and amendment. They include clinical research, dictation notes and audio recordings of patient phone calls.
Physicians close their practices for a variety of reasons: they may retire, merge with a larger practice or health system or sell the business. Patients should obtain copies of their records before the physician’s office closes.
A medical record is a set of documents that contains information regarding a patient’s health history. It includes information like diagnoses, medicines, tests, and vaccinations. In addition, it also records the treatment protocol. Keeping well-documented medical records is crucial for doctors and their patients. They serve 2 important purposes: they help the doctor to evaluate a patient’s condition and plan a treatment protocol, and they are also used as evidence in case of a malpractice suit.
Documentation that comprises the Medical Record may physically exist in multiple locations, both in electronic and paper formats. The Legal Medical Record is a subset of the Designated Record Set and is the record that will be released for purposes of legal proceedings. Other than the Legal Medical Record, documentation can be considered a Clinic Record / Shadow File when it is used solely by clinicians in their office or clinic settings. This is distinguished from the Legal Medical Record because the document entries in a shadow file must be authenticated by a Medical Staff member using a signature stamp or computer key that complies with UC’s signature standards.
The medical establishment relies on records to evaluate the patient’s condition and plan treatment protocol. The legal system also depends on these documents in cases of malpractice litigation.
Physicians must allow patients to inspect their records or receive copies of their records upon request. This includes records transferred from previous physicians.
Documentation that comprises the Medical Record may exist in paper and/or electronic formats in different locations within UC___. Generally, the Medical Record is the collection of the original documentation that constitutes a patient’s legal medical history and clinical research records that include written or dictated notes and/or source material (e.g., photos, films, ECG recordings, fetal monitor strips, dental models/casts).
The medical record should be legible and understandable to individuals other than the author. The authenticity of an entry can be established by using a signature stamp or computer key when the medical staff member places it on an authenticated signature line. If an error is discovered in a recorded entry, the original entry should not be obliterated; rather, it should be amended with the correction.
As the flu pandemic takes its toll, many independent practices are closing or merging. Physicians leave their practice for a variety of reasons: they retire, they sell their practice to a larger entity, they merge with another physician or hospital, or they shut down their practice due to financial problems. It can be difficult for patients to get copies of their medical records when this happens.
Moreover, the ability to easily transfer electronic medical records (EHR) from one clinician’s system to another is an explicit expectation in Stage 1 of Meaningful Use guidelines for EHRs. This allows patients to take their own information with them as they move between specialists, hospitals, nursing homes, doctors’ offices and across the country.
If an entry in a clinical note needs to be changed, make sure you write the new information on every line of the record. Skipping lines leaves room for tampering. Also, if you need to strike through an entry rather than overwriting it, do not just cover the text with whitener; this is a clear indication of tampering.
The medical establishment is obligated to protect the integrity of the record by not permitting its destruction or disclosure without due process of law. It also must not permit unauthorized access to the record. Inactive records should be stored in a secure environment, with appropriate safeguards to prevent loss or destruction.
Paper records should be securely locked or covered to minimize incidental disclosure of personal identifiers. Computerized records should be validated to ensure accuracy and consistent intended performance.
Physicians often close their practices for a variety of reasons. They may merge with large hospitals or health systems, retire or sell their practice, or be forced to shut down due to financial constraints. Patients need to know how they can obtain their medical records if this occurs. The medical board or state medical society should be able to provide information about physician requirements in this area. Moreover, patients should be able to file complaints when the medical records of a physician have been closed or transferred without proper notification to the patient.