Paper Example on Preserving Patients' Health Records: Vital Info & EHRs

Paper Type:  Essay
Pages:  5
Wordcount:  1233 Words
Date:  2023-05-03


Preserving patients' medical records classify the patient, besides it covers facts about a patient's health condition and diagnosis. Documentation of a patient's health history comprises of vital medical information, such as demographics, vital signs and symptoms, diagnoses, prescriptions, treatment procedures, progress notes, challenges, immunization periods, allergies, radiology pictorials, and test and laboratory outcomes. Health facilities deploy systems like electronic health records (EHR) and print media, among others, to document health information of their patients.

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Q2. Importance of Maintaining Complete and Accurate Records

Appropriate medical records, such as electronic or printed, enhances patients' safety and care. Medical personnel receives intercession from medical or clinical complaints when they observe proper medical documentation procedures. Suitable documentation in healthcare facilities improves communication and offers a window for exercising clinical judgment, reduces health jeopardy, and provides effective and efficient healthcare provision for patients.

Q3. The Privacy Act of 1974 and the Health Insurance Portability and Accountability Act of 1996.

The Privacy Act of 1974 developed a program of impartial information procedures that regulates the gathering, preservation, use, and broadcasting of information about people that entails sustaining a mechanism of record confidentiality by government agencies. The act, therefore, protects personalities from unwanted access to their data. The health insurance portability and accountability Act of 1996 ensures patient safety through exercising best practices in the management of information in fields such as administration, physical security, and technical security. The two Acts enhance patients' personal healthcare information by providing frameworks that ensure that healthcare providers maintain professionalism concerning their patients' documented records.

Q4. Ownership of a patient's Medical Record and Accessibility.

The physical medicinal record belongs to the medic who documented it and the healthcare facility in which the medical history originated. The patient possesses the data of the first medical record collected by the medical personnel. Patients, therefore, get a duplicate of their personal medical information, but not the original document. Patients have the patent right to ensure that the facts entered in the healthcare document is authentic, and has the liberty to petition the healthcare facility provider to correct accurately improper information in the medical record. Patients and medical professionals, thus, have the right to access patients' data.

Q5. Importance of Medical Records in Legal Proceedings.

Medical records are referring to legal, medical documents admissible in a court of law detailing a patient's medication and diagnosis history applied as a subpoena duces tecum. Medical practitioners must keep medical records to safeguard them against legal lawsuits from patients and other entities since they can come under extreme scrutiny in case of an allegation of negligence. During a claim of negligence, contemporaneous documents of all decisions arrived at by a healthcare provider, and the justification concerning those decisions is essential. Medics rely on accurate, legible, and complete medical records as a form of defense.

Q6. Medical Record Battleground

Medical record background refers to the field in which the medical records become the epicenter of a lawsuit in which the petitioner questions the admissibility of the document based on its documentation. The medical record battleground arises when there exists an allegation of meddling with the medical records after documentation. Medical records do not involve registering complaints about a person or a facility but entail an essential aspect of recording a patient's course of medical procedure.

Q7. The distinction between Verbal, Written and Implied Consent.

Verbal Consent entails the process in which the receiver of the Consent reads or gets a version of a consent form, such as an information sheet, and patrons give their verbal permission to participate in the place of written consent. The consenting participants must have the chance to ask questions and provided a copy of the instruction sheet. Written Consent refers to an official binding document signed either on print or digitally (recognized legally) by parties permitting to undertake specific actions. Implied Consent involves informing the prospective subject about an effort that requires completing an anonymous questionnaire. Through the completion of the survey, the patron agrees to get involved in the activity.

Q8. Role of the Patient, Physician, Nurse, and Hospital in Obtaining Informed Consent.

The patient or their lawyers must provide Consent willingly and without any intimidation by others. They must ask questions and seek clarification until they feel satisfied about the procedure, the gains, the risks, and possible options. The physician, or any other licensed independent medical professional, must offer the patient with full data concerning the treatment or procedure, potential dangers like pain and complications, the benefits of the program, the person who will undertake the procedure or treatment, and any probable options. The nurse performs verification processes and ensuring that the client or the legal representative signs the consent agreement form in their presence and that the clientele, or the representative of legal age and mentally competent to give Consent. The nurse must also confirm that the patient has adequate knowledge to make sound decision. The hospital must verify and recognize that informed Consent obtained from the patient or the legal representative is legally binding. The hospital must also prove that the Consent obtained is well documented.

Q9. Unnecessary Circumstances for Parental Consent for a Minor

Medical care for a minor whose parents are under detention or accused of committing sexual abuse requires no consent. Besides, children require no parental consent when receiving routine examinations and medical treatments so long as they have reached the age of 14 years old. Other medical care that needs a minor not to seek parental Consent involves abortions, HIV/AIDs tests, and psychiatric hospitalization.

Q10. Rights and Responsibilities of Patients as Reviewed in this Chapter.

A patient has the right to receive treatment with courtesy and respect, dignity, and the need for privacy. A patient also has the right to ask questions and receive reasonable answers and requests. Besides, patients have the right to know their healthcare provider and the personnel responsible for their treatment and medical procedures. Patients have the right to information regarding their conditions, and refuse any treatment, except as otherwise provided by law. Patients also have the right to receive, upon request, reasonable estimates of charges for medical bills and a receipt containing an explanation of the expenses. Furthermore, patients have the right to indiscriminate treatment in any facility, emergency medical care, and whether the treatment involves experimental research to offer their Consent or refuse. Patients have the right to complain and express their grievances concerning a medical staff or the healthcare facility without prejudice.

A patient must provide accurate and full information about their medical history to help the medical professionals to document and provide an appropriate diagnosis. Patients must also report any unexpected changes in their condition during treatment. Besides, patients must communicate to the healthcare provider whether they understand instructions issued by the medical personnel. Patients need to follow treatment programs, keep appointments, and following the hospital's rules and regulations. Finally, patients must ensure the settlement of their hospital bills.Q10. Patients' Importance to Prevent Medical Errors.

Patients can ensure a reduction in medical errors through the provision of accurate and complete medical history to the medics. Besides, the patients can seek clarification on instructions or issues they do not entirely comprehend to avoid miscommunication. Moreover, patients can find interpreters if there exist language barriers between the medical provider and the patient. Patients must further adhere to the rules and regulations of the health facility, maintain appointments, and follow instructions regarding prescriptions and treatment procedures.

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Paper Example on Preserving Patients' Health Records: Vital Info & EHRs. (2023, May 03). Retrieved from

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