Legal Aspects of Health Information Management

1. Should corrections be date-and time-stamped? Medical records should be clinically and legally accurate and any information that may be erroneous in nature needs corrected. There may be instances in which patient himself would be finding mistakes in medical records and would be making changes to them, by themselves. They would be using vernacular nomenclature, which medically may not be correct. This would also lead to a lot of disagreements between physician, other healthcare providers and patients.

Medical records may be a source to cause a lot of disputes and issues between various healthcare providers. It would not be ideal for physicians to change or amend information by themselves. Instead, it would be better for m to attach a note, explaining mistake and also providing correct information. Hence physician, signs, and puts date and time along with this correction note, accuracy and credibility of information is increased, thus helping to improve quality of medical care and reduce the errors, and clearly documenting processes.

Patient would not be authorized on their own to make changes in medical records concerning clinical judgments, treatment options and the decision-making, which they would consider being erroneous. If patient notes an error in decision-making in records, such an error may be authorized by clinical staff, although it is not mandatory to correct it (as patient may often pressurize physician to make changes). Physician need not concentrate wholly on correcting errors in medical records. Adding the date and time so that such changes can clearly be documented (Margaret A. Hamburg, 2000).

2. When should the patient be advised of existence of computerized databases containing medical information about the patient? When physician makes a note of patient information and records it in medical records, he would have to transfer and release information into a database. Before physician or healthcare provider releases this information into database, person’s maintaining database should make physician aware of existence of medical information of patient in various or entities or databases.

Person maintaining database from a particular organization would be having some sort of access, with varying amount of rights to access information. Such information of the patient needs to be recognized well in advance. Before accessing information, consent of patient is required. Databases should assign various levels of security to information depending on sensitivity of data (Margaret A. Hamburg, 2000 and William L. Manning, 2008).