How to Manage Health Records.

Health Records are documents that expound the patient's details such as medical history, diagnostic tests outcomes, clinical results, medication and progress of the patient, and pre and post operatives care. If properly managed, medical records support the correctness of the doctor's treatment. Medical records are also a fundamental source of information for healthcare attorneys. This article discusses various aspects of health records management.

Importance of Health Records Maintenance.

A well-maintained health records system serves the interest of both the patient and the medical practitioner. Therefore, doctors need to document the treatment of their patients correctly. The art of keeping health records has evolved into a science. Quality health records are the key to many medical negligence claims' dispensability since health records are the only source of truth.

Therefore, it is recommendable that institutions and hospital management apply more effort to improve the standard of their health records maintenance. The importance of health records maintenance includes the following:

• Monitoring the treatment of the patient

• Serves as evidence of medical malpractice suits

• Facilitates medical research

• Facilitates dental/medical or paramedical training

• Health records are essential documents in personal injury suits, insurance cases, workers' compensation suits, will, and criminal suits.

Access to Health Records.

Health records are confidential documents. Health records should not be released to another party without the consent of a patient. The following are persons eligible for accessing the medical records of a patient:

• Medical practitioners involved in the treatment of the patient.

• The patients themselves have the right to access and keep copies of their medical records.

• The health records attorneys of the patients.

• Parents in cases where the patient is a minor.

• Health records should be presented when summoned in a court of law in suits involving cases such as medical negligence, insurance claims, and traffic road accidents.

• Researchers can also access health records. However, the identity of the patients is not revealed.

Release of Health Records.

The following notes should be considered when releasing health records documents.

• Honor the health records' release request and issue them to the patient or authorized person as soon as possible.

• Uphold the certificate register with health records information. The documents should contain the patient's identification mark and signature.

• Install a computerized health records system.

• A summons to produce health records is a kind of court order. Failing to adhere is in contempt of court and is punishable. Summoned health records should be presented to the court but not to the solicitor who demanded it.

• Certain documents should be issued to the patient unconditionally, which includes referral notes, discharge summaries, or any death information. They should be given to the patient or authorized persons freely. 

• Medical practitioners are not obliged to surrender or produce patients' medical records to the police without a valid court warrant.

Compliance is Important.

Maintaining and protecting health records are essential to both the patient and medical practitioners. Health centers and hospitals should acquire an efficient and reliable health records system and comply with HIPPA regulations in protecting the privacy of the health records.  Our attorneys are experienced in guiding healthcare practitioners and practices in implementing HIPAA compliant health records systems and resolving legal matters involving access and release of health records.