Claire Dawson
Medical records are legal documents that are subject to the laws of the country or state in which they are produced. They are prepared by various healthcare professionals, including physicians, nurses, physician assistants, and therapists, who document a patient's medical history, physical examination findings, and daily updates during hospitalisation. Speech-language pathology assistants (SLPAs) may also contribute to documentation by collecting data and preparing charts, but they do not sign formal documents without the co-signature of a supervising speech-language pathologist (SLP). SLPs are responsible for identifying payer requirements and ensuring correct diagnoses are reported in documentation. Licensees are ultimately responsible for safeguarding medical records, providing timely access, and ensuring the adequacy of their entries and clinical decision-making.
| Characteristics | Values |
|---|---|
| Who prepares hospital documents? | Doctors, nurses, physical therapists, dietitians, clinical pharmacists, respiratory therapists, etc. |
| Who owns the hospital documents? | This depends on the laws of the country/state in which they are produced. In Canada, the healthcare provider owns the records, but the patient owns the information contained in them. In the US, the employer owns the records if the provider is an employee of a clinic or hospital. |
| Who has access to hospital documents? | The patient or their legal guardian/representative. |
| What is included in hospital documents? | Physical examination, vital signs, muscle power, examination of organ systems, daily updates, clinical changes, new information, diagnoses or disorders, patient instructions, etc. |
| What are the requirements for hospital documentation? | This varies depending on the payer, but generally includes why the patient was seen, what assessment or treatment was provided, clinical findings, and any recommended treatment. |
| How are hospital documents stored? | As paper records or converted into electronic charts. |
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What You'll Learn
Medical records staff
The specific duties of medical records staff involve the collection, organisation, and secure storage of patient information. They receive and process patient data, update records with new information, and ensure that the records are complete and up-to-date. This involves collaborating with other healthcare professionals, such as doctors, nurses, and therapists, to obtain and incorporate their clinical notes and observations into the patient's medical record.
In addition to data entry and management, medical records staff are also responsible for safeguarding patient information. This includes implementing appropriate administrative, technical, and physical safeguards to protect patient privacy. They must be knowledgeable about relevant laws and regulations, such as state record retention policies and HIPAA rules, to ensure compliance and maintain the security of sensitive medical data.
Furthermore, medical records staff may be involved in the conversion of paper medical records to electronic health records (EHR). They need to be proficient in using EHR systems and aware of their limitations to ensure accurate documentation and clinical decision-making. This includes understanding the potential errors or omissions that may arise from the system's intricacies and taking responsibility for any necessary adjustments or updates to the patient's information.
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Speech-language pathology assistants (SLPAs)
To become a certified SLPA, individuals must complete specific educational requirements and clinical fieldwork. In terms of education, options include obtaining a bachelor's degree in communication sciences and disorders, an SLPA degree, or completing online training. Additionally, clinical fieldwork requirements include a minimum of 100 hours of experience, consisting of 80 hours of direct patient/client/student services and 20 hours of indirect services, all under the supervision of an SLP.
Once certified, SLPAs may be involved in documenting student, patient, or client performance. This includes collecting data, preparing charts, records, and graphs, and reporting this information to their supervising SLP. However, it is important to note that SLPAs do not sign or initial formal documents, such as plans of care (POCs), reimbursement forms, or reports, without the co-signature of their supervising SLP. The extent to which SLPAs can provide and document clinical services and receive reimbursement may vary depending on the payer, state, facility, or program.
The American Speech-Language-Hearing Association (ASHA) provides guidance and regulations for SLPAs, including an Assistants Code of Conduct to ensure ethical practice and the welfare of consumers. SLPAs must adhere to state laws and regulations regarding record retention and privacy protection, such as HIPAA rules, to maintain the integrity and confidentiality of patient information.
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Medical professionals
Medical records are legal documents that can be used as evidence, and they are subject to the laws of the country or state in which they are produced. These laws govern the production, ownership, accessibility, and destruction of medical records. For instance, under Canadian federal law, the patient owns the information in their medical record, but the healthcare provider owns the physical record. In the case of an employee of a clinic or hospital, the employer owns the records.
In the United States, state laws regarding record retention are passed by the state legislature and can be found on the state's website or the Department of Health's website. Hospital medical records staff should be knowledgeable about these laws and regulations. While HIPAA regulations do not include medical record retention requirements, they mandate the application of safeguards to protect the privacy of information. The Centers for Medicare and Medicaid Services (CMS) requires that patient records for Medicare beneficiaries be retained for five years.
Medical records typically include a patient's medical history, physical examination findings, and daily updates documenting clinical changes and new information. This information is entered by all members of the healthcare team, including doctors, nurses, physical therapists, and dietitians. When a patient is unable to make decisions about their care, a legal guardian is designated to access their medical records and make decisions on their behalf.
Licensees, including healthcare professionals, are responsible for safeguarding and protecting medical records under their control. They must facilitate the release of records to patients or their representatives in a timely manner and ensure adequate security measures. Licensees are also responsible for the accuracy and completeness of their entries in the Electronic Health Record (EHR) system and cannot solely rely on the system for decision-making. They must be aware of the limitations of the EHR system and adjust their practices accordingly.
Speech-Language Pathologists (SLPs) play a specific role in documentation. They are responsible for identifying the requirements of each payer and ensuring that the correct primary diagnosis is reported in the documentation. Speech-Language Pathology Assistants (SLPAs) may also document patient performance and report this information to their supervising SLP, but they do not sign or initial formal documents without the supervising SLP's co-signature.
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Licensees
Medical records are legal documents that are subject to the laws of the country or state in which they are produced. In the case of US state laws, these may be found on the state's website or the Department of Health's website.
The Board has cautioned against the overuse of template content or reliance on EHR software that pre-populates information from one encounter to the next without the licensee carefully reviewing and updating all information. Direct licensee-patient communication via a "patient portal" can facilitate communication, but it also places a responsibility on the licensee to provide timely responses to legitimate requests from patients for feedback or information.
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Patients/guardians
Medical records are legal documents that are subject to the laws of the country or state in which they are produced. In the case of patients who are unable to make decisions regarding their care, such as minors or those with incapacitating illnesses, a legal guardian is designated to access their medical records and make decisions on their behalf. These guardians can be a next of kin or appointed by a court of law.
As a patient or guardian, you have the right to access and receive a copy of your medical records from the healthcare provider or hospital. This process may vary depending on the state and country, but you can generally submit a request to the medical records department or the relevant healthcare provider. There may be a reasonable fee associated with obtaining these records, and the format may be electronic or physical copies.
It is important to note that you, as the patient, own the information contained within your medical record, but the healthcare provider or facility owns the physical record. This means that while you have the right to access and review your medical information, the original records remain with the healthcare provider.
Additionally, you should be aware that medical records typically include a range of information beyond just your medical history. This can include personal details such as your name, identifying numbers, addresses, and contact information. This information is crucial for locating and identifying patients and ensuring proper care.
In certain situations, you may need to provide consent for others to access your medical records. For example, if you are undergoing a medical emergency and are non-communicative, consent to access your records is typically assumed unless you have previously documented your wishes in an advance directive or similar documentation.
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Frequently asked questions
Hospital documents are prepared by a variety of healthcare professionals, including doctors, nurses, therapists, and medical record staff. Each document is tailored to the patient's needs and may include information such as observations, vital signs, and treatment plans.
Hospital documentation serves multiple purposes, including:
- Recording patient information, such as medical history, symptoms, and observations.
- Planning and justifying treatment by documenting clinical findings, diagnoses, and recommended procedures.
- Facilitating communication between different healthcare professionals involved in a patient's care.
Access to hospital documents is typically restricted to authorised healthcare professionals involved in the patient's treatment. In some cases, patients or their legal guardians may also access their medical records, depending on the patient's capacity to make decisions.
Hospital documentation is subject to various laws and regulations, such as state or federal legislation, that govern their production, ownership, accessibility, and retention. For example, the Health Information Technology for Economic and Clinical Health Act, implemented in 2009, encouraged the conversion of paper medical records to electronic formats.
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