APMA News - July/August 2013 - (Page 36)

Coverage Corner By Larry M. Waranch, Esq., and Christina N. Billiet, Esq. The Dos and Don’ts of the Legal Medical Record A patient’s medical record serves many purposes. It is used not only to document patient care, but also for financial, research, and quality improvement purposes. A patient’s medical record also serves an important legal purpose: It can be admitted in court as evidence in a malpractice case or in a personal injury case as evidence of a patient’s past or current medical condition. At some point in your career—and most likely, on many occasions—you will be asked to produce a patient’s medical record. This production could be in response to the patient’s request, or it could be mandated by a subpoena. The reasons for the disclosure may vary; the patient might be changing providers, may want a second opinion, or may be involved in a malpractice case. It is important to know that what you are really being asked to disclose is the patient’s legal medical record. The legal medical record may differ from what you consider to be the patient’s medical chart. Thus, prior to responding to a patient’s request or a subpoena, it is vital that you understand what is included within the legal medical record. Just as importantly, you must understand what is not. Disclosure of the appropriate legal medical record is crucial to protecting yourself and your patient, as well as ensuring that you do not run afoul of HIPAA privacy rules or ethical guidelines governing the doctor–patient relationship. Keep in mind that disclosure of the appropriate legal medical record is also important when defending yourself against malpractice allegations. The legal medical record consists of all documents and other materials in your possession relating to the history, examination, diagnosis, and treatment of a patient. When asked to produce a legal medical record, do produce: patient intake forms and questionnaires; history and physicals; progress and office visit notes; nursing and/or assistants’ notes and assessments; laboratory and pathology reports; operative and procedure reports; consent forms; imaging reports (as well as copies of the films themselves, if requested—e.g., X-rays, CT scans, MRI scans, ultrasounds, etc.); consultants’ reports; medication records; communications with other health-care providers regarding the patient (e-mails, letters, phone messages, etc.); communications with the patient (e-mails, letters, phone messages, etc.); any medical records in your possession from other health-care providers; death certificates and autopsy reports; and photos of the patient. • • • • • • • • • • • • • • • 36 APMA News July/August 2013 Do not produce: incident reports; peer review materials; morbidity and mortality (M&M) case reports; communications with your medical professional liability insurer; billing records (unless specifically requested); any information regarding inquiries by the board of podiatry; or communications with lawyers other than the patient’s lawyer. • • • • • • • These days, the legal medical record may not be contained in a patient’s “paper” file. You may need to produce printouts of electronic records, films, CDs, photographs, or the like. Many hospitals and some practices now use EHR systems. While the benefits of using an EHR can be great, EHR systems also present new obstacles when a patient’s medical record is requested. For example, “screens” change and it can be impossible to replicate exactly what the health-care provider saw when he or she created a medical record. If you use an EHR system, you need to work with your software contractor to ensure medical records are properly created, managed, and preserved over time. The same medical records which exist in a traditional “paper” medical record must be kept in the EHR. Likewise, when asked (or ordered) to produce a patient’s legal medical record, you must produce the same records from an EHR that you would produce from a patient’s “paper” medical record. Keep in mind, however, that electronic records are often organized differently, and some information may appear in a different format. There are numerous types of patient records, not all of which can be listed in this article as a “do” or a “don’t.” At some point in your career, therefore, you will almost assuredly come across a circumstance not addressed here. For example, you may wonder whether an obituary, or correspondence with a patient’s family after that patient’s death, should be produced as part of the legal medical record (the answer is no). If you are unsure whether a particular record should be produced as part of a patient’s legal medical record, call your medical professional liability insurance carrier for guidance. n Larry M. Waranch, Esq., is national counsel to the Podiatry Insurance Company of America (PICA) and is a managing member of Waranch & Brown, LLC, in Lutherville, MD. Christina N. Billiet, Esq., is an associate at Waranch & Brown, LLC. Contact PICA Director of Risk Management Barbara Bellione, RN, CPHRM, ARM at 800-251-5727, ext. 2052, or e-mail bbellione@picagroup.com.

Table of Contents for the Digital Edition of APMA News - July/August 2013

APMA News - July/August 2013
President's Message
Contents
Destination Hawaii: The National in 2014
Arizona Study Finds Podiatry Saves Lives and Reduces Expenses
Committee Nominations Requested
US Naval Podiatrist Trains Afghan Orthopedists
The Man Behind the Marketing: The New Face of Student Recruitment
The Benefits of Working with Residents
Bylaws Propositions Due
Health Policy and Practice Committees Meet to Tackle Reimbursement Issues
Reimbursement
ICD-10: How to Code a Typical Infection
Federal Advocacy Forum
Cosponsors to the Helping Ensure Life- and Limb-Saving Access to Podiatric Physicians Act
APMAPAC Chair Report
Resolutions Submission Deadlines
Coverage Corner
IT Consultant
Inside APMA’s Social Media
Website Wisdom
On the Road with APMA
Small Business 101
CPME Update
Young Physicians’ Accomplishments
In Short
Worthy of Note
Affiliates Corner
List of Affiliated Organizations
New Members
Death Notices
APMAPAC Update
Development Update
Annual Scientifi c Meeting Sponsors
Classified Advertising
Dates to Remember
Advertising Index
10 Questions
Your APMA

APMA News - July/August 2013