Patients' Rights and Access to Medical Records Essay
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Patients' Rights and Access to Medical Records
The confidentiality of patient visits and medical records are essential in providing the highest quality of health care. Under penalty of law, a patient's medical records or any other information regarding the patient may only be released with his or her authorization. Exceptions to this are certain cases specified by law for example, health care providers are required to report certain communicable diseases such as measles. Many organizations and laws have been developed to maintain patient's rights of confidentiality and access to their medical record. Guided by the principle that confidentiality is essential in developing strong trust between patients and healthcare providers, the…show more content…
The first principle is that with very few exceptions, health care information about a consumer should be disclosed for health purposes only. The information should be easy to use for those purposes, and very difficult to use otherwise. The second principle is that technical security safeguards be maintained for computerized data. Including audit trails that identify who accessed the data and the prosecution against anyone who used the records for illegal or improper purposes. The third principle is consumer access. The patient should have ability to access his or her records and know others that also have access to them. Patients should be aware of the laws, regulations, and policies that protect their information. The fourth policy is defined as accountability, which is of relation to security and consumer control. Fines and imprisonment are required to those who breach security of personal health information. The final policy is public responsibility. Legislation must be balanced between personal, private interests and national priorities of public health, research, and law enforcement. The excessive flow of information, without patient authorization, is essential to the immediate discovery and investigation in public health crisis. AHIMA's acknowledgement of these five principles are abroad outline of a sensible public policy that balances personal privacy
To assure that the basic rights of human beings for independence of expression, decision and action, concern for personal dignity and human relationships are preserved for all patients, and to define the responsibilities of patients seen at University Health Conway
It is the policy of University Health to respect the individual rights of all persons that come to this facility for care. Patient rights include the right to make decisions regarding medical care, the right to accept or refuse treatment, and the right to formulate advance directives (written instructions, such as a living will or durable power of attorney for health care as recognized under Louisiana state law, relating to the provision of such, when an individual is incapacitated). Patient responsibilities include those actions on the part of patients that are needed so that healthcare providers can provide appropriate care, make accurate and responsible care decisions, address patients' needs, and maintain a sound and viable health care facility.
A. Access to Care
Individuals shall be afforded impartial access to treatment that is available and medically indicated, regardless of race, creed, sex, national origin, religion, sexual orientation, disability or source of payment. Free translation services are available.
B. Respect and Dignity
The patient has the right to considerate, respectful care at all times, under all circumstances, with recognition of his personal dignity and worth.
C. Privacy and Confidentiality
The patient has the right, within the law, to personal privacy and information privacy, as manifested by the right to:
- Refuse to talk with or see anyone not officially connected with the hospital, including visitors, persons officially connected with the hospital but who are not directly involved in his care.
- Wear appropriate personal clothing and religious or other symbolic items, as long as they do not jeopardize safety or interfere with diagnostic procedures or treatment.
- To be interviewed and examined in surroundings designed to assure reasonable audiovisual privacy. This includes the right to have a person of one's own gender present during certain parts of a physical examination, treatment, or procedure performed by a health professional of the opposite sex; and the right not to remain disrobed any longer than is required for accomplishing the medical purpose for which the patient was asked to disrobe.
- Expect that any discussion or consultation involving his/her case will be conducted discreetly and that individuals, not involved in direct care, will not be present without permission of the patient.
- Have his/her medical record read only by individuals directly involved in treatment or monitoring of quality, and by other individuals only on written authorization by the patient or that of his/her legally authorized representative.
- Expect that all communications and other records pertaining to his care, including the source of payment for treatment, be treated as confidential.
- Expect that information given to concerned family members or significant other legally qualified person, be delivered in privacy and with due consideration of confidentiality.
- Request transfer to another available room if another patient or visitors in that room are unreasonably disturbing to said patient.
- Be placed in protective privacy and/or be assigned an alias name when considered necessary for personal safety.
D. Personal Safety and Security
The patient has the right to expect reasonable safety in so far as the hospital practices and environment are concerned. To address the needs of patient, visitor and staff regarding safety and security, the University Police patrol 24 hours per day and are present in the Emergency Room around the clock. Other safety and security measures include limited access to the facility through the use of electronic access cards and readers on exterior entrances, video monitoring in numerous areas of the campus, and the use of employee identification badges that are to be conspicuously displayed.
The patient has the right to know the identity and professional status of individuals providing service and which physician or other practitioner is primarily responsible for his care. This includes the patient's right to know of the existence of any professional relationship among individuals who are treating him, as well as the relationship to any healthcare or educational institutions involved in his care. Participation by patients in research programs, or in the gathering of data for research purposes, shall be voluntary with a signed informed consent.
- The patient has the right to obtain from the practitioner responsible for coordinating his care, complete and current information concerning his diagnosis (to the degree known), treatment, pain management, and any known prognosis. This information should be communicated in terms the patient can reasonably be expected to understand. When it is not medically advisable to give such information to the patient, the information shall be made available to a legally authorized individual.
- The patient has the right to formally access his medical records. The patient shall complete the Authorization to Disclose Protected Health Information (form #1148) which is then sent to Health Information Management for processing. The Manager/Charge Nurse is to be notified when such requests are made.
- The patient may access, request an amendment to, and/or receive an accounting of disclosures of their own protected health information as permitted under applicable law.
- The patient has the right of access to people outside the hospital by means of visitors, and by oral and written communication. The patient may request not to be included in the patient directory. Inclusion in the patient directory means that the patient's name; room number and a general condition report may be given to people who ask about the patient by name.
- The prisoner patient has the right to visitors only as approved by the warden of the prison or jail where the prisoner patient is incarcerated.
- When the patient does not speak or understand the predominant language of the community, or is hearing impaired, he/she shall have access to an interpreter if at all possible. This is particularly true where language barriers are a continuing problem.
- The patient has the right to reasonably informed participation in decisions involving his/her health care. To the degree possible, this shall be based on a clear, concise explanation of his/her condition and of all proposed technical procedures, including the possibilities of any risk of mortality or serious side effects, problems related to recuperation, and probability of success. The patient shall not be subjected to any procedure without his/her voluntary, competent, and informed consent, or that of his/her legally authorized representative. Where medically significant alternatives for care or treatment exist, the patient shall be so informed.
- The patient has the right to know who is responsible for authorizing and performing the procedures or treatment.
- The patient shall be informed if the clinician proposes to engage in or perform human experimentation or other research/educational projects affecting his/her care or treatment, and the patient shall sign an informed consent if participation is desired and maintains the right to refuse to participate or withdraw from any such activity at any time.
- The patient may refuse treatment to the extent permitted by law. When refusal of treatment by the patient or his/her legally authorized representative prevents the provision of appropriate care in accordance with ethical and professional standards, the relationship with the patient may be terminated upon reasonable notice.
- If a patient is unconscious or is determined to be mentally incompetent and no consent can be obtained from an appropriate family member, legal action may be taken to obtain a court order for diagnostic and therapeutic procedures. In life-threatening emergencies, where the patient is incompetent or unconscious, appropriate treatment may be administered without consent.
The patient, at his/her own request and expense, has the right to consult with a specialist.
J. Transfer and Continuity of Care
- A patient may not be transferred to another facility unless he/she has received a complete explanation of the need for the transfer and the alternatives to such a transfer, and unless the transfer is acceptable to the other facility. The patient has the right to be informed by the responsible practitioner or his/her delegate of any continuing healthcare requirements following discharge from the hospital.
- Regardless of the source of payment for his/her care, the patient has the right to request and receive an itemized and detailed explanation of his/her total finalized bill for services rendered in the hospital. The patient shall be informed of eligibility for reimbursement by any third-party coverage during the admission or pre-admission financial investigation.
K. Hospital Rules and Regulations
The patient shall be informed of the hospital rules and regulations applicable to his/her conduct as a patient. The hospital's Notice of Privacy Practices is available from the Admitting Department or can be found on the hospital website.
L. Complaint Process
The patient has the right to file a complaint regarding services and is entitled to information regarding the hospitals mechanism for the initiation, review and resolution of such complaints.
M. Patient Responsibilities
Patients have the responsibility for:
- Providing accurate and complete information about medical complaints, past illnesses, hospitalizations, medications, pain, and other matters relating to their health.
- Following the treatment plan recommended by those responsible for their care.
- Their actions if they refuse treatment or do not follow the healthcare team's instructions.
- Seeing that their bills are paid as promptly as possible; following hospital rules and regulations.
- Being considerate of the rights of other patients and hospital personnel.
- Seeking information, and in the event they have questions, asking them.