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Changing Notes in Medical Records: A Proposal

Published online by Cambridge University Press:  01 January 2021

Susan Babin
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Extract

The hospital medical record is a multi-purpose document. It is the repository for all relevant (and sometimes not so relevant) medical information concerning the care and treatment of a patient during his or her stay in the hospital or visits to the Out-Patient Department or Emergency Ward. In addition, it serves as a form of communication among all past, present and future providers to help them provide medical care to the patient. With the gradual disappearance of solo practice as a major mode of health care delivery, and with the emergence of group practices, Health Maintenance Organizations, neighborhood health centers and hospital based primary care programs, this communicative function assumes even more importance. As a legal document, its existence is mandated by statute in many states, and it is frequently used as evidence in malpractice suits and other court proceedings. The medical record also serves as a research resource from which statistics and findings can be compiled to aid in a variety of studies and medical audits. Finally, it is an educational document which often is employed as a teaching tool in training students in the health field.

Type
Article
Information
Medicolegal News , Volume 6 , Issue 1 , Spring 1978 , pp. 4 - 8
Copyright
Copyright © American Society of Law, Medicine and Ethics 1978

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References

See, eg., Mass. Gen. Laws Ann., c. 111, §70 (hospitals and clinics licensed by health department required to keep records of the treatment of the cases under their care).Google Scholar
Accreditation Manual for Hospitals (Joint Commission on Accreditation of Hospitals) p. 93.Google Scholar
Hirsh, H.L., Medical Records - Their Medico-Legal Significance, Journal of Family Practice 2: 213–16 (1975) [hereinafter cited as Hirsh].Google ScholarPubMed
Mass. Gen. Laws Ann., c. 111, §70 (except for hospitals under control of department of mental health, licensee must permit inspection of record by patient to whom record relates or by his attorney upon delivery of written authorization for patient); see Globe, Boston, March 1, 1974, Medical Records Available But Hospitals Make You Fight To See Yours, at 1.Google Scholar
Shenken, B.N. Warner, D.C., Giving the Patient his Medical Record: A Proposal to Improve the System, New England Journal of Medicine 289: 688–91 (1973).CrossRefGoogle Scholar
Hirsh, , supra note 3, at 214.Google Scholar
Hirsh, , supra note 3, at 214.Google Scholar
See note 1 supra.Google Scholar
See note 2 supra; 20 Code of Federal Regulations §405.1026: Mass. Regs. vol. XIII, part 9, c. II:2.Google Scholar
20 Code of Federal Regulations §405.1026(g).Google Scholar
See Mass. Gen. Laws Ann., c. 111, §54 (department of public health empowered to order an audit of the medical records required kept under licensing provisions).Google Scholar
Rotan v. Greenbaum, 273 F.2d 830, 831 (D.C. Cir. 1959).Google Scholar
Report of the Secretary's Commission on Medical Malpractice (Department of Health, Education and Welfare, publication no. OS 73–88) at p. 77.Google Scholar
Hirsh, , supra note 3, at 214.Google Scholar
Pyramid Life Ins. Co. v. Masonic Hospital Ass'n of Payne County, 191 F. Supp. 51, 54 (W.O. Okla. 1961) (keeper of record not entitled to possess and use record to exclusion of patient, his representative or those standing in his shoes).Google Scholar
Annas, G.J., The Rights of Hospital Patients 115 (1975).Google Scholar
Canneil v. Medical and Surgical Clinic, 315 N.E. 2d 278, 280 (III. App. Ct. 1974).Google Scholar
See note 2 supra.Google Scholar
See, e.g., Collins v. Meeker, 424 P. 2d 488, 498 (Kan. 1967).Google Scholar
Prosser, W., the Law of Torts 739 (4th ed. 1971) [hereinafter cited as Prosser].Google Scholar
Prossser, , supra note 20, at 746.Google Scholar
Prosser, , supra note 20, at 738.Google Scholar
Berry v. Moench, 8 Utah 2d 191, 331 P. 2d 814, 820 (1958).Google Scholar
See Roth v. Greensboro News (Co., 217 N.C. 13, 6 S.E. 2d 882, 887 (1940) (honest mistake in publication of libelous article will not protect publisher).Google Scholar
Prosser, supra note 20, at 789.Google Scholar
Gaetano v. Sharon Herald Co., 426 Pa. 179, 231 A. 2d 753, 755 (1967) (no cause of action for libef arises until publication of defamatory matter occurs).Google Scholar
Stone v. Essex County Newspapers, Inc., 311 N.E. 2d 52, 59 (Mass. 1974) (defendant may introduce evidence of retraction in mitigation of damages).Google Scholar
Roth v. Greensboro News Co., 217 N.C. 13, 6 S.E. 2d 882, 888 (1940) (retraction must be a full and fair correction, apology which clearly admits falsity of original article); Brogan v. Passaic Daily News, 22 N.J. 139, 123 A.2d 473, 478 (1956) (retraction must be in as public a manner as that in which defamatory charges were made).Google Scholar
Hayt, E. Hayt, J. Legal Aspects of Medical Records 35 (2d ed. 1977).Google Scholar
Id. at 36.Google Scholar
Roth v. Greensboro News Co., 217 N.C. 13, 6 S.E. 2d 882, 887–88 (1940).Google Scholar