1.Mr. Carter was a patient in the hospital last month and he is now requesting t
ID: 347478 • Letter: 1
Question
1.Mr. Carter was a patient in the hospital last month and he is now requesting that he be given his medical records because “after all, the records are about him”. As the Release of Information (ROI) Clerk, it is your responsibility to interact with patients when they have a request. There are several parts to this initial discussion question. First, what legislative acts would oversee the ROI process? Discuss the issues surrounding the concept of who legally owns a health record and the health information contained therein. What issues should be considered if health information is captured and stored electronically? Secondly, knowing all of this, how would you specifically convey it to the patient? 1.Search the Internet for two professional and/or scholarly sites addressing disclosure of sensitive information such as HIV, Alcoholism, Drug Abuse, Mental Health, etc. Post the specific legal and HIM operational guidance that you can take away and apply to your learning from the sites, along with the links.
Explanation / Answer
Legislative acts would oversee the ROI process:
Issues surrounding the concept:
Although a medical record can be said as physical property of a hospital, however, the patient controls the release of the information contained in his/ her record. Authorization access from a patient is critical but information can be disclosed without patient’s permission under certain circumstances- for treatment, payment or operations, by law. Patients can/ request access to all the evaluation and treatment information in their record. Also a patient has right to get, an appropriate counselling to understand the medical information, apart from access to medical record information. Also, no information can be deleted (but can be corrected) during the period till the information needs to be archived.
Issues should be considered if health information is captured and stored electronically:
Data breach, data security issues, hacking by unknown sources, can result in Identity theft or any other misuses in personal/ professional/ legal conducts.
Hence, proper authorization to access/ edit records should be limited and based on safe and updated technology, free from any kinds of bugs/ viruses.
Convey it to the patient:
Politely make patient aware of his rights regarding access to medical records/ information/ counselling. Make patients aware of rules and regulations by the Government and hospital. Any legal work, as per legislature framework should be clear to patients before admitting them for treatment and during discharge to avoid any confusion. Humbly communicate, what are Dos and Don’t Dos for patient and hospital both. Provide information on respective designated authorities to handle any escalated issues, doing the proper quality control.
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