Legally speaking, medical records are owned by a Physician or health-care institution, but the information contained within the medical record is the property of the patient. The patient has an absolute right to access the information contained in the medical record, which is covered by all the same rules of confidentiality as any other privileged medical information.
In the case of a chart error, the doctor should draw a line through the error, and initial next to the correction. Hence, anyone reading the chart would see the original content, and this ensures that medical errors are not being concealed.
Pages cannot be removed from medical charts, and “white out” cannot be used. If a Physician forgets to put a note in the chart documenting a patient’s condition on a prior day, the note cannot be backdated, and must always reference the current date and time.
A Physician cannot release a medical record without the consent of the patient, and no one except those directly involved in the care of the patient has a right to access the record.
Patients cannot take sole possession of the physical medical record, but they have a right to access or copy the information, and a medical record cannot be withheld to force a patient to settle medical bills. The patient’s right to his/her medical record information outweighs the physician’s unpaid medical bills.
Q7 Your patient requested a copy of her records from the community hospital. Her request was declined, as she needs a specific reason to obtain her records. She sees you at your office and is requesting your guidance. What should you tell her?
A-Only a healthcare institution, insurance company or physician can access her medical records.
B-The hospital will provide her the medical records if a physician asks
C-She has every right to have a copy of her records.
D-Only the physician can obtain and review her records.
Q8 A 60-year-old female presents to the clinic complaining of feeling faint and dizzy for the past two weeks. Her past medical history is significant for diabetes mellitus type II, hypertension and osteoarthritis. She takes metformin, lisinopril and occasional nonsteroidal anti-inflammatory drugs to alleviate discomfort from her osteoarthritis discomfort. Her documented blood pressure at the office two weeks ago was normal and the plan clearly indicates to maintain the same medical regimen. However, there is also a note in the chart from a colleague to increase the dose of her antihypertensive medication.
During the office visit, her blood pressure is at 110/60 with significant orthostatic changes upon standing. What will be your best course of action?
A-explain that pharmacy made an error in dosage
B-apologize and explain that a colleague made a mistake in her chart and apparently her blood pressure medication dosage was increased.
C-Resume previous dose of her lisinopril without any further disclosure
D-report the error to the medical board