Contents Legal system Malpractice Avoiding malpractice Medical record Introduction Proper documentation Subjective vs objective Legal considerations Managing records Record storage Releasing records Viewing records Withholding records Selling records FAQs Patients' rights QUIZ

Managing medical records: Who owns them? It has generally been accepted that the medical record is owned by the person(s) entering data in it (or the hospital or group employing the person(s)). With ownership comes the responsibility of storage and maintenence of the record as well as the responsibility of protection from destruction, loss, theft or alteration. The advent of computerized medical records, with the integration of inpatient and outpatient records (and thus integration of different institution's records), is sure to add some interesting complications to questions of medical record ownership. Managing medical records: Storage Active records: Records that have been added to or used in the previous two years should be considered active. Older records: Most attorneys recommend that medical records be kept indefinitely. Although Connecticut state law requires that a hospital keep a record for 25 years after the discharge of a patient, and private offices keep records for 7 years after the last vist or 3 years after the death of the patient. Physicians, if able, should probably keep records as long as possible. Before destroying any medical records (of deceased patients, for example), it is probably wise to ask the patient's family if they desire a copy. Conversely, if a physician dies prior to selling (see below) or transferring records to another physician, the executor of the physician' s estate should attempt to contact all patients or patient's families prior to destroying the records. Records not claimed by patients or their families need to be transferred to another physician, or maintained for a number of years. Forms of storage for medical records Records of patients who are deceased, moved away, cared for by a new physician or otherwise not seen recently (ie >2 years), and records not claimed by the patient or family member, may be stored as closed files. These can be reduced to microfilm or microfiche (which usually requires a special consultant to assure proper, legal handling). Computerized medical record handling is such a new field that very few legal precedents exist. There are certain to be many issues around confidentiality, accessibility, and the ease with which data can be added or changed on a computer.