Physicians can be better prepared to transfer patient health information when they understand who has custody of and access to medical records.
Individuals have a general right to access their personal information in independent medical examination files, but there are exceptions to what must be produced
Physicians may release a patient’s medical records to lawyers only with patient authorization or where required by law.
Physicians working with medical scribes should be aware of their obligations as an employer, delegator, and supervisor.
EHR and EMR technologies change the way medical care is delivered, creating both opportunities and challenges for healthcare providers.
Adequate record keeping may help during a billing audit.
Physicians should try to accommodate patients’ requests to limit access to their personal health information.
Physicians should speak with patients about their alternative medicine treatments and, as much as possible, provide guidance on potential negative interactions.
The practice of marking transcribed reports or entries “dictated but not read” gives rise to medical-legal risks and can create uncertainty for those relying on that information in providing patient care.
Patient handovers can be a time of high risk. Patient safety experts recommend various strategies to improve the performance of this task.
A discussion of the principles of access, the challenges with access, and managing the risks.
Providing patients with online access to their electronic medical records may offer improvements in patient health. Physicians should keep in mind their obligations to protect patient information and document appropriately.
Tips for using electronic records and other technologies.
A sample of medico-legal questions posed by CMPA members to physician and legal experts at the Association's education programs.
An overview of the principles of retention, sharing and transferring of medical records.
Privacy legislation, regulatory policies and professional obligation require that CMPA members take reasonable measures to protect the privacy of their patients' personal health information. With the advent of electronic records, members should be cognizant that encryption can help secure personal health information and may be required by law.
To respond appropriately to a request to release patient information, physicians must understand the legal rules surrounding the ownership and handling of the information.
Litigation related to the placement of central lines is most often related to consent, delegation, standard of care, and documentation.
Poor charting may be perceived as reflecting less attention to detail and risks the conclusion the care provided was poor.
CMPA provides free telephone record pads for physicians to use when documenting telephone advice.
The physician's role in providing a child's medical information to a parent.
Physicians may be asked to attest to the capacity of a patient if the patient's will is contested or at the time the will is being prepared.
Notifying and transferring patients and medical records when making a practice transition.