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

Frequently asked questions (FAQ) Q. What do I do if a patient wants to tell me something that they want to keep "off the (medical) record"? A. Information pertinent to the care of the patient should always be documented in the record. If the patient persists in his/her desire to tell you things "off the record" the best option may be to terminate the relationship with that patient. Q. How much should I charge for providing a copy of a patient's record? A. In Connecticut, the fee charged by hospitals for copying a medical record cannot exceed $ 0.65 per page plus postage for hospitals and $ 0.45 per page plus postage for physician's offices. Q. What should I do if a patient's attorney requests information from the patient's chart. A. If the request contains an original signed, dated and recent (less than 1 yr. old) authorization from the patient for release of information, forward the requested items to the attorney. You should not prepare any explanatory statement or written summary. It is strongly recommended that you notify the Office of Risk Management so that further advice can be provided. And, of course, you may charge the usual fee for providing the copy of the record (see above). Q. Should I let a patient see his/her medical record? A. Maybe. Hospitalized patients are not usually allowed to see the record because it is not complete (i.e. it lacks lab and radiology reports, etc.). However, in order to defuse a situation, it may be prudent to allow a patient view his/her own record (with supervision) prior to it being complete. Q. Should Incident Reports become part of the medical record? A. No. The medical record should not contain information unrelated to the medical care of the patient. Entries in the record related an adverse incidents should be brief, factual and objective without speculation as to the cause of the incident. Incident REPORTS are internal documents for risk management and quality improvement purposes.