Patient Records and Health Information Management: Accuracy and Release
The record as a legal document
A medical record contains demographics, registration and consent forms, history, examination findings, orders, results, progress notes often in SOAP format, correspondence, medication and problem lists, and signed authorizations. Charting must be accurate, objective, timely, legible, dated, timed, and authenticated. The old saying holds: if it was not documented, it was not done.
Correcting and filing
Correct an error by drawing a single line through it, writing "error" or "mistaken entry," and adding your initials and the date, leaving the original readable. Late entries are labeled as late. Never erase, use correction fluid, back-date, or write in another person's entry. Paper records may be filed alphabetically, numerically, or by terminal digit and require sign-out if they leave the area.
Release of information
Records are released on a written, specific authorization after verifying the patient's identity, and only the minimum necessary information is disclosed. Treatment, payment, and health care operations generally do not require authorization. Know the difference between a subpoena and a court order, the patient's rights to access and to request amendment, the accounting of disclosures, state retention schedules, and destruction by cross-cut shredding with a certificate. In an EHR, role-based access and audit trails matter.
Traps that appear in questions
- Releasing records on a telephone request or to a spouse without authorization.
- Believing treatment, payment, and operations disclosures need written authorization.
- Confusing ownership: the practice owns the physical record; the patient owns the information.
- Ignoring amendment requests or HIPAA response timelines.
- Assuming electronic records cannot be subpoenaed.
Worked example. A note lists the wrong medication dose. Strike one line through it, write "error," initial and date it, then document the correct information in a new entry with the time. Never remove the original text.
Rule of thumb: disclose the minimum necessary, and remember the patient owns the information even when the practice owns the paper.