Law and Ethics in Healthcare

Case # 2

Yushika D. Wilson

October 13, 2014

HINF 4206

Department of Health Informatics

Introduction

As custodian of patient records, the Director of Health Information Services is having a great deal of difficulty responding to subpoenas for patient records.  The record conversion project is prominent among the challenges the Director is facing – the health care facility is in the midst of converting from a paper-based record to an electronic patient record.   Consequently, some information is on paper, some information is scanned immediately following discharge, and some information is captured by the new electronic health record system.  The process of finding and identifying the various parts of a patient’s record from the various sources is time-consuming and frequently the outcome is unsatisfactory.

Resources

Fundamental of Law for Health Informatics and Information Management. Second Ed. Revised.

Purpose

The purpose of this report is to describe what the custodian of patient records should do to handle record requests consistently, including ensuring that the compiled response is a true and complete record of the patient.

Procedures to Take

The custodian of patient records whether the record is electronic or paper have the responsibility of overseeing the care, custody, and control of the health record for the individuals of their organization that prepare and maintain records of health care. The health information custodian’s responsibility play an important role in the legal process.

  The process of finding and identifying the various parts of a patient’s record from the various sources is time-consuming, however very necessary. The principles to ensure both high quality patient care and a legally defensible health record that will be used as evidence in legal procedures are as follows: appropriate authentication, accuracy, authorship, approved abbreviations, legibility, completion, timeliness, appropriate use of the print...