Medical Records

Laws govern the collection, maintenance, and disclosure of information in medical records. Each health care institution also has policies and procedures regarding patient medical records. Medical records are not public documents, and the information they contain must be kept secure. Any breach in the confidentiality of information kept in a patient’s medical record risks legal liability.

In a lawsuit, both parties are permitted to use the patient’s medical record to argue facts of the case. Entries made in the chart often show whether the standards of care were met in a given situation. It is essential that the employing institution’s policies and procedures regarding the patient’s medical record be followed. All entries in the medical record must be permanent, accurate, complete, and legible. Two current trends potentially affect patient confidentiality. Many smaller health care organizations are merging to form large corporations in an effort to save resources while continuing to provide services. Also, computer-based health care records are becoming common.

Together, these two trends have the potential to vastly expand the numbers of people with access to confidential patient information. Those implementing these trends are required to take federal HIPAA pri­vacy standards into consideration and prevent unauthorized disclosure of medical records and patient information.