(Snippets from the frontline)
What happens in the hospital, stays in the hospital
A medical record is a legal document, but who owns it?
The doctor or hospital claims the right of physical ownership, but the patient owns the information and is allowed to “inspect, review, and receive a copy” according to HIPAA Privacy Rules.
Whether it be in an office or hospital, physicians provide an initial “History and Physical”, then subsequent follow-up in a “Progress Note.”
Words tell your story justifying treatment and reimbursement by insurance companies, while maintaining government regulations for quality measures.
Dotting all i’s and crossing all t’s is important (nowadays, they are dictated) to assure compliance and certification of care.
Some hospitals though tell physicians what they can, and can’t dictate into a medical record to conceal inadequate care. Why? To minimize hospital liability of course.
If care is delayed or denied, wrong medication given, utilization reviewer pressure doctors for discharge, nursing is understaffed, or treatment not done, then this should be part of the record as it effects patient outcome.
Good lawyers say, “if it is not documented, it didn’t happen.”
Make sure your doctor dictates all facts concerning your care.
What happens in the hospital should be in the medical record.
Gene Uzawa Dorio, M.D.
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