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

identification of abnormal findings, the recording of problems that will require
attention on future visits, and a way to ensure that the physician is notified if the
patient misses a follow-up visit.
The record should also contain family and legal information. For minors, the names
of the parents or guardians should be in the chart, and a prominent notation as to who
is legally able to consent to the child’s care. Most important, the chart should note
any special legal constraints, such as a parent who is not allowed to consent to care,
who is not allowed to pick up the child from the clinic, or who is not allowed to have
access to the child’s medical information. If patients have a living will or durable
power of attorney, this should be noted in the chart and a copy attached, if available.
Adult family information—spouses, children, significant others—should be recorded
and a note made if other members of the family are patients of the practice. The
medical care practitioner may review the other patients’ charts to look for medically
significant information, such as the risk of spreading infectious diseases between
family members. However, the medical care practitioner must not share one adult’s
medical information with another without the patient’s consent. If there is consent to
share information, it should be in writing and filed in the chart. If the medical care
practitioner believes that a patient may endanger others by spreading disease, then
the proper response is to report this to the public health authorities and ask for their
help and advice.
2. Team and Managed Care
In clinics with several physicians and other medical care practitioners, the demands
on the medical record begin to resemble those of a hospital medical record. All of the
medical care practitioners in the group must keep records in the same format, record
enough information to allow any other medical care practitioners in the group to treat
the patient, and identify patient problems with great specificity to ensure continuity
of care. It is very important that the each person who cares for the patient be clearly
identified in the chart. If nonphysician medical care practitioners are treating patients
under a physician’s supervision, the supervising physician should be clearly
identified in the chart. This can be a very important issue in Medicare billing because
of the rules on what care may be billed by what class of provider. It is important for
medical malpractice risk management to establish that state laws governing
supervision of nonphysician personnel are followed.
Clinics where the patient sees whichever medical care practitioner is available at the
time the appointment is made create the opportunity for patient problems to be
ignored through shared authority for patient care. As with hospital-based care, the
ideal is that there is one physician in charge of the patient’s overall care, and that the
chart identifies this physician. The chart will be returned to this physician for review
whenever the patient is treated by another member of the clinic group. This review
allows the primary physician to reconcile the care of the other providers. If there are
problems, the patient can be contacted. If there are no problems, the reviewing
physician can add whatever notes are necessary to ensure that the next physician to
see that patient has the proper information. In systems where this is impossible,
368