Public Health Law Map - Beta 5 - Medical and Public Health Law Site

programs monitor the care provided as closely as the private companies. At times the
government will audit medical care providers to make sure they are complying with
Medicare or Medicaid rules. The auditors will examine hundreds or thousands of
medical records, with full access to all patient information.
D. What is in the Medical Record?
Hospitals keep the most complete medical records. Hospitals must follow the
guidelines of private accrediting organizations such as the Joint Commission on the
Accreditation of Health Care Organizations, as well as standards set by the state and
federal government. These guidelines specific the basic organization for the records so
that records from different hospitals will be organized in the same way. This makes it
possible for medical care providers to work in different facilities without having to
learn a different system of records management for each facility. It also allows
government and insurance auditors to review records and compare them between
hospitals.
The medical record must include the tests that are ordered, their results, the orders for
all drugs and treatments and the record that they were done, the nurses notes
documenting the patient's condition at a regular basis, the physician's notes reviewing
the patient's condition, the physicians instructions to the nurses, consent forms and
other legal documents related to the patient's care, and the observations and orders of
any other medical care providers seeing the patient. If the patient has surgery, there
will be a note outlining the surgery and its outcome, and when the patient is discharged
from the hospital, there will be a note documenting the patient's conditions and all the
arrangements for follow-up care. The medical records are not stored in a single record
but are distributed throughout the recordkeeping system of the hospital. The patient's
medical chart is the physical record that stays with the patient, usually at the nurse's
station, and has the day to day care records. The hospital pharmacy will records on the
patient, as will the laboratory, and the results of tests such as x- rays and MRI scans
will be stored in the laboratories that do the tests. There will be administrative records
about the patient if the patient's care is reviewed by a hospital committee. The billing
department will have its own records about the care that rendered and the billing for
that care. Some of these records will on paper and others will be electronic. In time,
most will be electronic.
A patient who stays in the hospital a few days with a serious illness may have a dozen
people working on the primary medical chart and a dozen more working with records
in other parts of the hospital. The record might be used 20 - 30 times a day. A patient
in a large medical center hospital for a week for complicated care might have more
than 100 people working with some aspect of a patient's record, and many of those
people would use the record several times. Parts of the record may be sent to outside
consultant physicians and to diagnostic laboratories if tests are ordered that cannot be
performed in the hospital. The accounting department will prepare a detailed list of all
the procedures, diagnoses, drugs, and devices used on the patient and send it to the
insurer for payment. If the patient is suspected of having a communicable disease, the
public health department will be notified and may investigate the patient's records,
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