Ethical and Legal Issues in Healthcare

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Medical Records: The Fundamentals

Introduction
More than ever, it is critical that hospitals and other healthcare organizations have systems and procedures in place that abide by, and maintain patients' records according to legislative laws and HIPAA guidelines. Additionally, such health records should be created, designed and maintained in an ethical, confidential and legal manner.

Discussion
All entries into the medical record will be authenticated by the employee/person who made the entry. Signed and written signatures and in some case even initials, electronic signatures, and computer-generated e-type signature codes are also acceptable as authentication. The medical record entries will also include all observations, concerns, queries, notes, and orders etc., made by care providers in a relationship with the patient/resident, and others who are authorized to do so. Finally, all signatures and/or initials, written, electronic, or computer-generated, shall include the initials of the signer's credentials (JCAR, n.d.). As such, as a part of the risk-management department for an assisted living facility it would be critical that the following contents be included but not limited to part I of the facility's patients' medical records policy.

Medical Records Policy: Part 1
Contents
The Patient Profile should contain demographic information such as: The current date; Name(firs, middle, and surname); Phone number; Gender; Address; Age; Marital status , Place and Date of birth; Education and Occupation; Current weight(any recent loss or gain in weight), as well as:
• Health insurance information
• Current medications and treatments
• Next of kin and emergency contacts(home and cell phone numbers)
• Illnesses and surgeries(if any) allergies to medication (if any)
• List of current doctors and their contact information
• What patients are currently being treated for
• Any current stressors or major life altering circumstances?
• Family medical history, especially anything that patient could be predisposed to (i.e. breast cancer, heart disease, diabetes).
• Date of last annual physical
• Age of first Menstruation and history(if applicable)
• Age of onset of menopause and history (if applicable)
• Cognitive information-Is patient's memory (and all other senses intact) (seems coherent)?
• Is patient sexually active-and if so, do they practice safe sex?
• Do they have kids-How many? Any history of sexual or physical abuse
• Sleep patterns, any major complaint, and history of the complaint
• Lifestyle choices, how they eat, do they drink or smoke, and if so how often?
• Do they exercise, and if so how often?
• Past hospitalizations; recent losses; changes in marital status etc.,
• Bowel patterns:(recent movement and any significant changes)
• (If/where/when applicable) Results of initial examination should be recorded and should include blood pressure measurement, weight, height, and visual /eye ...