Health record information stores sensitive patient information. Attorneys for healthcare organizations use this data to protect patient rights, identify risks, and avoid lawsuits. When you need a lawyer to represent you in court, choose one who specializes in health law. An understanding of the law will make all the difference in your case. Attorneys who have worked in the health field are well-versed in healthcare records and how they can help you.
Identify risks and protect the rights of patients
Health record information provides a wealth of information for healthcare attorneys. Using the health record to assess risks is a critical component of patient privacy. Attorneys can analyze how much information may be compromised and whether the patient should be notified. They may also analyze the risks posed by extenuating circumstances. A risk assessment can be done in-house or by an outside contractor.
Protected health information is a patient’s private medical and health history, including name, social security number, email address, telephone number, and medical record number. It may also include biometric identifiers and geographic information, full-face photographic images, and any other comparable image. These documents could provide unauthorized parties with valuable information that could enable them to determine the patient’s identity.
Document difficult patient encounters
If you’re an allied health professional, you’ll no doubt encounter difficult patients. These patients are likely argumentative, hostile, or non-compliant with your care. These patients can occur in any setting, from treating minors to dealing with difficult family situations. Documenting such encounters can help you protect your practice. But how do you properly document them? First, you need to know how to identify them.
For example, if a difficult patient demands medical records, do you document those encounters? If you do not, you’ll need to defend yourself against a malpractice lawsuit. Make sure to have your records prepared and organized by following your organization’s policies. The patient’s family may threaten to bring a medical malpractice suit, so make sure you have the legal authority to give them their records. Remember that all records should be documented with objective information. Document your patient’s statements, physical posturing, and other pertinent data. These records can be important in court or for legal claims.
If a patient’s behavior is inappropriate, you should document the interaction with the patient, and attribute the patient’s statements to the individual. You must also document threatening behavior. If a patient becomes violent, the situation should be reported to 9-1-1 or security. Documenting the encounter in medical records is crucial for protecting both the physician and the patient. A physician should seek medical regulatory authority advice and consult a CMPA if he or she is unsure of how to handle a difficult patient.
Maintain a legal health record
Medical records must be maintained to meet the legal requirements. This includes documents, but data can also be maintained in a legal health record. Digital photography, video, and diagnostic images can all be part of a legal health record. Organizations must declare such records in a policy to ensure they comply with the law. Records management software can manage the life cycle of these records. Organizations must also develop a process for disclosing this information.
As part of the policy development process, healthcare organizations should establish a legal health record definition and process for maintaining a legal health record. This document should describe how an organization will define its designated record set. Identifying a legal health record for business purposes is a crucial step in making sure that data is accurate and protected. Organizations should also make sure that staff is trained on LHR policies. The training provided by staff will assist them in fulfilling their specific roles and duties.
Once a patient has provided consent, the healthcare organization must create procedures for the identification of external information. External information may have legal implications that require it to be included in the patient’s record. The health care organization should include such information in its patient’s record in a separate tab or section. The state statutes may require it, but it is the responsibility of the organization to establish appropriate procedures to ensure compliance with this rule.
