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

Withholding medical record information from a patient Parents of minors In situations of suspected child abuse or where custody/visitation rights have been denied to one or both parents, access to a minor's record by that(those) parent(s) is usually not allowed. Adult patients In unusual and uncommon circumstances, a physician may deny a patient access to his or her medical record. This usually occurs in a psychiatric settings or institutions dealing with EtOH and drug abuse and/or the mentally disabled where, in the opinion of the physician, "great harm" would be done to the patient by allowing access to his or her record. When can a physician release information without a patient's approval? Reportable illnesses/injuries. Physicians MUST report cases of communicable diseases and other reportable illnesses as outlined in state statutes. Reporting of these conditions takes place without the patient's permission. Child abuse Suspected cases of child abuse must be reported to child protective agencies which, in turn, examine the medical record without the patient's or guardian's permission. Releasing records other treating physicians As noted above, some physicians have patients sign an authorization to release records as necessary to any consulting physicians, labs, etc. at an early visit. This is good policy. The release of records or information without a signed authorization to another care provider is a legal grey area. AIDS and HIV HIV and AIDS are sure to generate new controversies in the management of, and access to, medical records. Drug and alcohol abuse The Federal Drug Abuse and Treatment Act of 1972 (21 U.S.C. s 1175) established that patient records relating to drug and alcohol abuse treatment are unlike other medical records and are held as confidential unless a court determines that the potential benefits of releasing such records outweigh the risks of injury to the patient (and the patient-physician relationship). This statute has resulted in courts which are reluctant to order the release of drug and EtOH abuse treatment records. Selling medical records When a practice is sold, some of the assets changing hands are the office equipment, real estate (if any) and remaining contracts for services, however , the largest asset in the practice is usually the medical records of the patients seen in the practice. Although the records are owned by the physician, the information in them is technically owned by the patients, and as such, each patient should probably be contacted prior to transfer of ownership. If a patient refuses to allow transfer of records, or cannot be located, the selling physician should probably retain the record. This has rarely been examined in court; however, the era of HIV/AIDS and the confidentiality issues surrounding these diseases will probably stimulate more interest in this topic.