The Importance of Keeping Accurate, Confidential Patient Records - Essay Example

Keeping of medical records is a standard practice in healthcare, which is practiced by all medical s throughout the world. A medical record is a document, which is prepared and stored by a health facility, containing information regarding a particular patient treated in that facility. Such information may include and not limited to; name, date of birth, occupation, marital status, type of ailment, drugs administered, date of admission as well as other notes by doctors (Judson, 2009). However, the fact that such information is left in the custody of such institutions does not mean that it is their sole property. The patients are the true owners and as such, they can and are supposed to be allowed unconditional access to it. In addition, they should be consorted in advance and their permission acquired before such information can be disclosed to other parties in line with medical ethics and the Hippocratic Oath, which demands patient privacy as one of the building blocks in healthcare provision (Saunders, 2002). Traditional methods of record keeping mostly relied on paperwork and physical files but with the advent of technology, most institutions serving the public, including health facilities, have continued to embrace paperless offices, which rely on electronic databases and information management systems that can facilitate remote access to the patient records (Callahan, 2000). There are various reasons why keeping medical records is necessary both to the patient and the health institution as well as the state. To begin with, human beings are prone to different forms of sicknesses, which may be new to them or as a result of recurrence. For this reason, it becomes necessary to maintain details of such occurrences so as to enable the doctors to examine the history of such patients after which they would be able to make informed decisions on the best medications to prescribe. This may be important especially in cases where patients may have, in the past, showed signs of incompatibility with certain drugs, which may be due to allergy or other biological reactions in the body that can harm the patient. With such knowledge, the doctor can decide to change the prescription in order to avert such negative reactions to treatment. Some people, for example, are commonly allergic to penicillin and though the effects are not considered to be life threatening, they are advised to avoid the drug unless they are in a life threatening situation which cannot be treated using other substitute drugs (Karki, 2001). In addition, a patient may want to relocate to another state or locality far from the medical facility where he or she has been obtaining treatment and medication. In such a circumstance, a copy of the records would be necessary for the patient to be able to continue being treated by other doctors from different institutions and if necessary, the current doctor may find it necessary to contact the previous doctor to enquire or to confirm issues that are not clear to him. Without proper record keeping, it would be difficult for such a doctor to provide assistance owing to the fact that hospitals are public facilities, which serve numerous patients, some of whom have names or details that are similar therefore making it almost impossible for a doctor to remember them. It may also be notable that some illnesses are inheritable, such as Type 2 diabetes, hemophilia among others and this may be information that a doctor may want to know so as to be sure of what may be the root causes of a patient’s illness (Judson, 2009). Record keeping is also advantageous to the patient based on the fact that it compels doctors to be vigilant and more careful when administering treatment. This is because every doctor is supposed to append his signature on every record such that it becomes easy to identify him incase a patient decides to take legal action for any harm that may result from issues such as wrong diagnosis and drug prescription. In addition, medical records are important as they act as evidence, which a patient may use to defend him self in court or to claim for financial benefits from institutions such as the United States Social Security Administration. This is a federal government agency which mandated with the responsibility of insuring citizens against disability and retirement. However, in order to benefit from this social insurance, for example on the basis of disability, a thorough review of the claims is done by the Office of Disability Adjudication and Review. In this context, a patient may be required to produce records from more than one health provider in order to strengthen his case and convince the office to approve the benefits (Mason, 1998). Similarly, patient medical records are of great importance to the government as they provide data, which is significant for setting up health strategies (Karki, 2001). This is due to the fact that they facilitate strategists with information such as prevalence rate of diseases, outbreak of new diseases as well as the general health of citizens. The government may not be able to combat conditions such as cancer, HIV/AIDS, Diabetes, cholera, typhoid among other chronic illnesses without having to establish the magnitude of the dilemma at hand. With information compiled from various hospitals, it becomes possible, for example, to know the rate at which HIV infections are growing in the country as well as the groups of people who are highly vulnerable to the infections. This can help the government to determine how much money should go towards procuring preventive devices such as condoms or antiretroviral drugs to prolong the lives of those infected with the virus. New outbreaks of diseases such as cholera, polio and typhoid among others would be easy to notice through documentation and this would enable the government to set up emergency funds and act accordingly with regard to the areas that are affected. In addition, there are organizations and medical training institutes, which are involved in conducting research and statistics on various diseases and health conditions in the society. In order to come up with quality and factual conclusions, they must be able to access data from records available in the health facilities (Mason, 1998). For example, if an organization is researching on the health impacts of domestic violence or drug abuse in a certain category of people, it might be cumbersome and tedious to move around collecting information from unwilling victims. On the other hand, it would make their work easier to go into hospitals and ask for information on the number of people, for example, who are admitted and treated every month for conditions related to their queries. In this context, the hospitals would be able to assist by referring to the records in their possession. However, such information, as stated earlier, cannot be disclosed without the consent of the patients unless the data being obtained is general such that it does not disclose the identity of the patient in question. Article 8 of the European Convention on Human Rights as well as the Data Protection Act 1998 protects the citizen’s right to information privacy and as such, any person who feels that his private life has been compromised through unauthorized disclosure of his or her medical information can go to court and sue the perpetrators, whether doctors or other third parties (Rowe, 1998). However, special circumstances have been set aside through legislation, which allows third parties to acquire such information without the consent of the patients. These are for example the Public Health Act 1984, which allows doctors to report any diseases that require government attention. The terrorism act of 2000 also requires all citizens to disclose information that would assist the authorities to apprehend terrorists and this means that if a patient is admitted and is suspected of being a criminal, the doctors have the responsibility of notifying the police without it being considered unethical. Doctors are also obligated to avail the police with information, with regard to the Road Traffic Act 1988, so as to assist them in apprehending drivers, who may have committed a crime. Looking at these examples, one may conclude that patient records requires to be treated with utmost confidentiality unless there is reasonable grounds to believe that withholding such information may result to the harming of citizens or obstruction of justice (UK Clinical Ethics Network, n.d). Bibliography Callahan, J. (2000). Privacy and Confidentiality of Health Information. Jossey-Bass UK Clinical Ethics Network (n.d). ‘Confidentiality: Legal Considerations.’[Online] Available at: http://www.ethics-network.org.uk/ethical-issues/confidentiality (Accessed: 8 November 2011) Judson, K. (2009). Law & Ethics for Medical Careers. Career Education Karki, R. (2001). Medical Record and its Importance. Blackwell Mason, A. (1998). ‘Administration of Out-Patient Records.’ Journal of Management in Medicine Vol. 3(1): 26 - 37 Rowe, H. (1999). Data Protection Act 1998: A Practical Guide. Tolley Publishing Saunders, J. (2002). Patient Confidentiality. Medicode Read More