What right does a patient have to access medical records? What to do with medical records when a doctor dies, sells or leaves a doctor`s office? Can physicians charge patients for copying medical records? A medical record is a document that relates to a patient`s medical history, diagnosis, prognosis or health condition and is generated in the context of health care. Since many legal and ethical considerations must be considered before medical records are destroyed or discarded, it is strongly recommended that a record retention policy be implemented before records are destroyed or discarded. This policy should establish a detailed procedure (taking into account all legal and ethical considerations) for assessing the retention period of each medical record. A checklist and decision matrix can be developed to determine how long a file should be kept. Once adopted, the Directive should be reviewed at least once a year to ensure that it continues to comply with all relevant laws and ethical considerations. (b) sign each entry with the name, title and function of the medical personnel who registered it; How should a physician keep his or her medical record? The Act does not directly address patient access to records maintained by a private physician; However, the American Medical Association (AMA) has stated that all medical records should be provided to patients upon appropriate request. These medical records should not be withheld if a patient is not paying for medical services. Electronic medical records (“EMRs”) have become increasingly common in health care. As EMRs are increasingly used and implemented, the question often arises as to how long medical records should be retained. The request is usually made because it concerns physical medical records; However, the record retention considerations discussed in this article apply to both physical health records and EMRs.
As a general rule, it is recommended to keep medical records indefinitely if possible. However, there may be times when it may not be practical for a health care provider to continue to keep all of their medical records. In these circumstances, relevant legal and ethical considerations must be carefully considered. The provisions of the HIPAA Health Information Portability and Accountability Act of 1996 (“HIPAA”) require relevant companies (most healthcare providers) to retain the patient-signed HIPAA Privacy Notice for at least six (6) years. This notice is usually kept in the patient`s medical record. However, in some cases, medical records may be disclosed if: A patient`s medical record is a confidential document that should not be disclosed to third parties without the patient`s consent. A physician may be disciplined for breach of confidentiality. Ohio State Laws and Regulations That Affect Your Medical Practice If you have any questions about medical records or documentation, or other health administration questions, please contact one of our members in the Health Care Practice Group. The Ohio law does not directly address the issue of charging patients to access their medical records. However, the AMA said doctors may charge a reasonable fee for copying services. Although Ohio does not have a specific law requiring medical records to be retained for a minimum period of time, a number of Ohio and federal laws must be considered when deciding how long to keep medical records. Please note the following: Ethical Considerations: Under the Revised Ohio Code § 4731.22(B)(18), physicians licensed to practice medicine in the State of Ohio may be sanctioned by the Ohio State Medical Council if they violate the ethical rules of the American Medical Association (“AMA”).
As a result, all Ohio physicians must comply with the AMA`s ethical mandates. WADA Ethics Notice 7.05 deals specifically with the retention of medical records. The opinion cites prescription considerations as well as specific references to Medicare`s 5-year retention requirement and rules for treating a minor. In addition, the statement states that immunization records must be retained indefinitely. The statement also states: “Medical considerations are the primary basis for deciding how long to keep medical records.” In addition, prior to the destruction of a medical record, the physician must attempt to contact the patient and give the patient a reasonable opportunity to request the records or have them sent to another physician. What is patient record confidentiality? Ohio laws do not specifically address a physician`s obligation to keep medical records. However, licensed health facilities must retain medical records for at least 6 years from the date of discharge. It has been suggested by the medical authority that doctors keep their records for at least the same period, 6 years. Limitation Considerations: It is recommended that all medical records be retained for at least one period equal to the limitation period associated with the treatment performed. Under Section 2305.113 of the Revised Ohio Code, a medical malpractice lawsuit must generally be filed within one year of the “cause of action.” There are limited exceptions to this general one-year statute of limitations, including a two-year statute of limitations for wrongful homicide cases and the lull in the law up to the age of majority for the treatment of a minor child. Due to the multitude of factors that must be considered in determining the prescribing period applicable to a particular patient, it is recommended that a case-by-case assessment be conducted to determine the retention period of a medical record according to the limitation criteria.
Ohio law does not specifically address the steps a practitioner must take when leaving a doctor`s office. However, according to the AMA, a physician should inform patients when leaving a group practice. In addition, a physician who sells his or her practice or the estate of a deceased physician may transfer his or her medical record if (a) all active patients are informed that the records will be transferred to another physician and (b) all patients have the right to have their records transferred to another physician of their choice. Medicaid patients: Ohio Revised Code § 2913.40(D) requires a health care provider to retain all records of a Medicaid patient`s treatment for a period of at least six (6) years. (e) Respond to a subpoena from the Medical Council. Copyright © Kern Augustine Conroy and Schoppmann, P.C. Used with permission. (d) Report abuse of children or the elderly in accordance with RC 2151.421; or The Ohio State Medical Association has issued the following guidelines to facilitate medical record keeping: (g) Visible indication of any allergy or contraindication of patients; (c) indicate the patient identification number on each page of the diagram; (b) the notification of communicable diseases in accordance with OAC Standard 3701-3-01; (i) Document instructions or documents intended for patients. e) Each entry should include: the type of contact with the patient, the reason for the contact, any information or treatment given to the patient, and plans for future treatment or follow-up; (a) record the complete date (month, day, year) of each entry in the record; (f) the examination and initialization of all notes taken by a non-physician;.