Medical Records

Topics: Health Insurance Portability and Accountability Act, Medical record, Electronic medical record Pages: 6 (848 words) Published: July 21, 2013
“Medical Records”

HCA 322 Health Care Ethics & Medical Law


“Medical Records” 1

Some of the laws that bind the professional that works with

medical records are the maintaining of patient medical information

such as doctors’ orders, test results, x-rays, the prescriptions of

different medications etc. Medical records must be precise,

complete, and protected by a health care provider so that the

Patient’s sensitive and personal information cannot be accessed

by any third party. Medical records are kept by law for 7 years,

and must be disposed of by a paper shredder or placed in a

medical records retaining box that holds such records until a

professional shredding company comes to retrieve them.

“Medical records” 2

The ethical issues that a medical records professional face daily

are the incomplete or falsifying records from a physician or a

medical staff employee, employees faxing or discussing patient

information to third parties, a patient’s chart in view at a

receptionist area or nurses’ station that can be seen by

others, and computers not logged off or monitors turned off when

an employee leaves the terminal. These mistakes are in direct

violation of Hippa (the Health Insurance Portability and

Accountability Act). A physician not completing a chart is also

“Medical Records” 3

a common mistake that should be corrected by the assisting

nurse. But there will be times when these records reach the

medical records department personnel and as a professional,

these records should be brought to the attention of the assisting

nurse or the acting physician. When falsifying occurs, despite the

reason, it should also be brought to the attention of the assisting

nurse or the acting physician. As we all know, that’s the correct

way of approaching something like this but in reality it would be a

different story.

“Medical Records” 4

When this type of problem occurs, some employees tend to

shy away due to reprisal and or termination. But most of the time,

when brought to the physician’s attention it’s corrected

immediately. It’s the responsibility of all medical staff as well as

the medical records personnel to comply with Hippa guidelines.

The Health Insurance Portability and Accountability Act or hipaa

Is a law that gives the right of privacy to individuals as young as

12 and must have a signed disclosure form from the patient to

release any information to third parties. Ethical issues that may

“Medical Records” 5

occur in a workplace would be employees discussing a

patient’s diagnosis or treatments with each other. It could go as

far as an employee discussing private information with others

such as friends or family outside the workplace. This happens

often in many hospitals as well as medical offices and clinical

settings and can cause such problems as other patients finding

out, being punished for not complying with the hipaa rules and

regulations which an employee can be terminated and /or do jail

time. The right thing to do is advise your coworker of the

“Medical Records” 6

wrong they are doing. If it does not stop, talk to the immediate

supervisor about the matter. A patient’s medical chart holds

valuable and important information and It’s very crucial that

nurses as well as medical records personnel handle these charts...

References: Wolf, I. (2011, Mar 20). Medical ID theft victims denied records; privacy laws are cited; health could hang in balance. News Sentinel (2007-Current). Retrieved from
State laws and court decisions define use of medical records to protect employee 's privacy. (1982). Employee Benefit Plan Review, 37(3), 32-32. Retrieved from
Zittrain, J. (2001). Many privacy laws can be applied to medical records. Ophthalmology Times, 26(5), 10-15. Retrieved from
Rubin, A. J. (1998, Sep 06). Medical records becoming less confidential congress considering laws to protect privacy. The Commercial Appeal. Retrieved from
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