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Documentation of Patient Care: An Often Underestimated Responsibility

Published online by Cambridge University Press:  27 April 2021

Jane Greenlaw
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Extract

There is increasing societal concern about retention and retrieval of information about individuals; advances in technology have enlarged the means for storing and communicating personal information. Not surprisingly, some of this concern is directed toward medical records. Questions have arisen about ownership of and access to medical records, as well as their content. This column focuses solely on some basic issues pertaining to the content of medical records.

Information in a patient's medical record can be used as a basis for decisions concerning his insurance coverage or payments, employment, eligibility for educational or benefit programs, or the outcome of a lawsuit. Thus, the law generally recognizes the patient's right to control the access to his medical record by third parties.

Because of the permanence and potential importance of a patient's medical record, health professionals frequently raise questions about what to include in the record, who should write in a patient's chart, where and how to make corrections, and how to document specific problems such as patient injury or concerns about the quality of care the patient is receiving.

Type
NLE Rounds
Information
Law, Medicine and Healthcare , Volume 10 , Issue 5 , September 1982 , pp. 172 - 174
Copyright
Copyright © 1982 American Society of Law, Medicine & Ethics

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References

See, e.g., Annas, G.J. Glantz, L.H. Katz, B.F., The Rights of Doctors, Nurses, and Allied Health Professionals (Avon Books, New York) (1981) at 170–92 [hereinafter referred to as Rights].Google Scholar
People v. Smithtown General Hosp., 402 N.Y.S.2d 318, 323-24 (N.Y. Sup. Ct. 1978).Google Scholar
Rights, , supra note 1, at 155.Google Scholar
For a listing of states that belong to each category, see Rights, , supra note 1, at 165, nn. 6, 7, 8.Google Scholar
Accreditation Manual for Hospitals, 1982 Edition (Joint Commission on Accreditation of Hospitals, Chicago) (1981) at 83–88.Google Scholar
Spoar v. Fudjack, 263 N.Y.S.2d 340 (N.Y. App. Div. 1965).Google Scholar
For a brief, cogent discussion of this point, including the distinction between nursing diagnosis and medical diagnosis, see Rights, supra note 1, at 24.Google Scholar
Pisel v. Stamford Hosp., 430 A.2d 1 (Conn. 1980).Google Scholar
Similarly, drugs that have been refused or omitted deliberately should be charted as such with a clear statement of the reasons for the refusal or omission.Google Scholar
See Darling v. Charlestown Community Memorial Hosp., 211 N.E.2d 253, 258 (Ill. 1965) (nurses were aware that a patient's leg cast was too tight and failed to notify hospital authorities when attending physician did nothing to alleviate the problem). For a discussion of the duty to report, see Greenlaw, J.L., Reporting Incompetent Colleagues, Nursing Law & Ethics; Part I, 1(2):4 (February 1980); Part II, Will I Be Sued for Defamation? 1(5):5 (May 1980).Google ScholarPubMed