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

keep personal notes, and often the nursing service maintains a centralized extra- chart
recordkeeping system. These records exist outside both legal and administrative
control. The records are kept in pencil, and old data are erased to make room for new
data, ensuring that decisions are based on current information. This process of
creating and erasing temporary records also carries over to the processing of
physician orders, which are transcribed from the medical record into the extra-chart
record. Once in the extra-chart system, it is easy to erase or mark out orders as they
are performed.
From a patient care perspective, extra-chart records provide a way to coordinate
patient care and provide ready access to laboratory test results. But these records are
deficient in that they provide no historical information. Extra- chart records
inevitably corrupt the accuracy of the chart itself because the extra-chart record
becomes the record that is filled out first, with the chart becoming a secondary
record, filled out when time allows. Secondary records often reflect what should
have been done rather than what was done. This causes medical problems if the
extra-chart system breaks down (someone loses the index cards, for example) and
legal problems if the care is challenged in court.
Physicians should never use off-chart records. All patient information must originate
in the chart and be transferred to notecards or other temporary records from the chart.
If notes are made separate from the chart, these notes should be glued into the chart.
They should not be copied over into the chart. Notepaper with strippable adhesive
should never be used for keeping medical notes. If they are inadvertently used, they
should be glued into the chart with a permanent adhesive.
6. Selling Medical Records
In many situations, the selling of a private medical practice is little more than selling
patients’ medical records. Interestingly, there have been few legal actions against
physicians who sell medical records. In many states, it is illegal to transfer medical
information for nontherapeutic purposes without the patient’s explicit permission. In
these states, the law would seem to require that each patient be contacted for
permission to transfer the records. If the permission is denied, the selling physician
will have to retain the records. If the patient cannot be located, then the record might
be transferred under seal to the buying physician, to be opened only if the patient
contacts the physician in the future.
It is expected that HIV/AIDS will precipitate a reexamination of the selling of
medical records. This will be especially threatening in states that make violations of
patient confidentiality a criminal act. Even in states that allow the transfer of medical
records as part of the sale of a practice, this transfer is limited to another physician,
not a lay practice broker.
C. Pediatric Records
With the exception of intensivists treating neonates, the care of children is a legally
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