| TOPICS OF INTEREST - MEDICAL RECORDS |
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| OMB ADMINISTRATIVE RULES ON MEDICAL RECORDS |
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Patient's Access to Physician Medical Records
847-012-0000 (1) Physicians shall make pertinent information in the medical record available to the patient. Physicians shall comply with the patient's written request within a reasonable time, not to exceed 30 days.
(2) At the discretion of the physician, disclosure of any portion of the medical record to the patient may be made in the form of an accurate representative summary of the factual information contained within the written account(s). Upon request, copies of pertinent x-rays will be provided in lieu of interpretive summaries.
(3) For the purposes of these rules, "medical record" does not include the personal office notes of the physician or personal communications between a referring and consulting physician relating to the patient. However, at the discretion of the physician, such notes and communications, or summaries thereof, may be included in the disclosure.
(4) If the physician disclosing the medical record to a patient believes, in good faith, that the release of any portion of the medical record would be injurious to the health or well-being of the patient, such disclosure of any portion of the medical record may be denied. The rationale for such a decision should be documented.
(5) The physician may establish reasonable charges to the patient for the costs incurred in providing the patient with copies of any portion of his/her medical record. Such charges may include cost of reviewing, summarizing and/or reproducing the original medical record and x-rays. However, a patient shall not be denied summaries or copies of his/her medical record because of inability to pay.
(6) Violation of this rule may be cause for disciplinary action under ORS 677.190.
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| COMMON QUESTIONS & ANSWERS ABOUT MEDICAL RECORDS |
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- I am about to retire - what do I do with my patient records? What kind of notice must I give my patients? What kind of notice do I give the Board? May I keep an active license?
It is suggested that Board licensees who are retiring from the active practice take the following actions:
- Notify patients by letter of the effective date of your retirement from active practice.
- Notify patients who do not require the immediate services of a health care provider where their records will be stored and who should be contacted in the event the records are needed. This information should also be reported to the Oregon Medical Board.
- Advise patients that they may either seek the services of another health care provider or that you will assist them in locating another health care provider through referrals from your office.
- Advise patients that their records will be forwarded to another provider of their choice upon receipt of a properly signed release form.
- Advise patients that their office will remain open for a reasonable length of time to facilitate the transfer of records and for the collection of outstanding accounts.
- Inform the Oregon Medical Board of the correct mailing address after retirement.
Whether or not a Board license can choose to maintain an active license depends on several factors. There are several options available. For questions about license status, call the Board's Registration section and your options will be explained thoroughly.
- How long must I keep my patient records?
The Oregon Medical Association recommends that physicians keep patient records, including those of deceased patients (adults and minors) for a minimum of ten years after the patient's last contact with the physician. If space permits, it is preferable to retain records of all living patients indefinitely. This recommendation applies to other licensees of the Board as well.
- Does my doctor or other Board licensee have to let me see my records if I ask?
Yes, with very few exceptions you have the right to access to your records. Keep in mind, however, that the actual records belong to the doctor. Oregon Medical Board Administrative Rule 847-12-000 states that upon written request, a copy or summary of the medical record must be made available to the patient. Physicians should comply with these requests within a reasonable time, not to exceed 30 days.
A reasonable charge for costs incurred in providing patients with a copy or summary of the record can be made; however, the patient cannot be denied the material because of inability to pay or because of an outstanding bill for previous services.
- My doctor or other Board licensee retired/moved--how do I find my records?
Contrary to what many people believe, there is no central storage place for medical records. The Board asks each retiring or departing licensee for an address where his or her medical records will be stored (often it is with a former partner or clinic). Once they provide the Board with that information, that address is put on the Board's computer, and may be obtained by calling (971) 673-2700 preferably between the hours of 1:00 and 4:00 p.m.
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| SUMMER/FALL 2002 OMB NEWSLETTER ARTICLE |
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Your Records, Your Friends
By Philip F. Parshley, M.D. OMB Medical Director
With the startling revelation by the Institute of Medicine in To Err Is Human that 44,000 to 98,000 deaths from medical errors occur in this country every year, emphasis has been placed on developing systems to prevent these errors rather than assigning blame to individuals. Every Oregon Medical Board (OMB) licensee can contribute to this process by reassessing the systems that lead to the development of medical records in his or her office. In addition, the medical record can be a healthcare provider's most valuable friend, when that provider is challenged by a malpractice suit, a hospital medical staff organization, the OMB or other regulatory organizations.
The standard of care requires a very complete documentation of every aspect of the medical care physicians provide their office patients. There are certain specific components that the OMB expects to find in the medical record.
First, it must be in the record and legible - or it didn't happen! Two pieces of pertinent information that frequently fail to make the medical records are progress notes you forgot to write or dictate, and telephone communications with the patients, consultants, former treating physicians, and the patient's family. Those who share call with you and your staff need readable information from your chart in order to assist you in providing quality care for your patients.
The SOAP (Subjective, Objective, Assessment, Plan) format is considered the standard of care with a separate set of entries for each major issue. The Subjective part is expected to contain a detailed history of the presenting issues, including identifying previous providers who have dealt with the present problems and what those providers did for the patient, a record of past illnesses, procedures, current medications, allergies, and a review of systems. The review of systems may be facilitated by a printed questionnaire which the patient completes. If you review the patient's responses on that form with the patient, perhaps with expansion of issues in your handwriting followed by your initials, date and time, you will demonstrate that you have reviewed the information.
The Objective part is a detailed complete physical examination that may vary based on the specialty of the examiner. This would also include laboratory and imaging results.
Your Assessment should include your reasoning for your diagnosis, as well as alternative diagnoses, if pertinent.
The Plan should have an explanation for your choice of action, especially if there are alternatives, and indicate the alternatives that were discussed with the patient. It is always a good idea to note that the patient was asked if he/she had any questions, and their answer. Note the expected date of revisit.
Physicians are currently being overwhelmed by more and more paperwork, but written protocols are very worthwhile to make certain that the professional providers and the office staff understand what is expected of them in all aspects of the practice. For example nothing is to be filed and buried somewhere in the chart without the pertinent physician's readable signature or initials. This includes everything from chart notes, to diagnostic studies, to copies of portions of the hospital records forwarded to the office, to consultant reports and virtually anything else that goes into the medical record in the office.
Your office should have protocols to see that preventive measures such as immunizations, screening procedures and counseling about tobacco, alcohol and drugs will be addressed in a timely manner. Protocols to track failed and canceled appointments, as well as failure to report for diagnostic studies or consultations, should be developed. If you are referred a patient for consultation and he or she fails to keep the appointment, notify the referring health care provider. You might consider a protocol to track follow-up procedures on previous problems.
Some other protocols that are strongly urged are policies on staff placing date, time and signature on any entries they make in the chart, handling telephone calls to the practitioners, phoning prescriptions, emergencies both in the office and those phoned to the office, threatening behavior toward staff or practitioner, and triage guidelines for staff giving response time according to category. These written protocols are important even in small medical offices with only one employee. Since there is inevitable turnover of staff, these written protocols will make orientation of new employees and additional practitioners much easier and more reliable.
The presence of a problem list and particularly a medication list, or even better, a medication flow sheet, has become the standard of care for any primary care provider or any provider who has patients receiving multiple medications or even a single medication on a regular basis. The medication flow sheet is considered critical if chronic pain is an issue as is a Material Risk Notice; the latter being required by law (Oregon Revised Statutes [ORS] 677.485 and Oregon Administrative Rules [OAR] 847-010-0030).
Electronic records will and are making records better, but there are drawbacks. Using voice-recognition computer software for medical records is risky unless you are willing to carefully edit and correct the final result. There should be some mechanism to prevent changes in the electronic record once the author has signed off on the content. If you dictate or use an electronic record, be sure you edit what comes back for errors and date the final result.
Hospital medical records usually document a much faster pace of events than those in the office environment. Under these circumstances, it is absolutely critical that the progress notes, orders and any acknowledgment of laboratory and imaging studies be dated and timed. The more critical is the patient, the more important the time record. Documentation of the note by time as well as date may save your bacon many times over.
Resist the urge to write in blank forms for lab results in a "progress notes," with plans to return and fill them in later in the day. This is a formula for disaster. A great deal can transpire between the writing of the progress note and the time when the laboratory reports are received by that physician. This could easily make the accompanying plan of action in that progress note inappropriate, negligent, and/or below the standard of care.
Do not in any way change the medical record. This is the kiss of death! If you are caught, you might as well ask how many pounds of flesh the plaintiff, the OMB, or the medical staff committee would like you to sacrifice. If you find errors later, make a dated and timed note of the changes without erasing the original. Better still, make a late entry in the current part of the record indicating the error and what you feel the correct entry should have been.
Promptly correcting errors transcription of your dictation acceptable. Even then, to be safe should initial and date the corrected copy. In this day and age, more patients have access to their records and may become incensed by they read. It is not uncommon receive a "demand" that the record be changed to reflect what the patient believes to be correct. you find that an error has been made you do not have to change your record. If an error has been made, you may change it as outlined above. If no error has been made you may acknowledge the concern of the patient in the record, but original entry may remain unchanged.
Specific procedures in the medical record keeping have changed with the passage of time, but not the need for such records, nor the importance of their accuracy and legibility. The difference between top-notch records and less than- desirable records can mean difference between a career saved and a career lost - not to mention limb, or a life!
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