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

The standards of care for pediatric preventive medicine are stringent. The federal
maternal and child health programs set explicit standards for developmental
screening. A physician in private practice cannot justify a lower standard of care for
health assessment than the child would receive in a community health center or from
the local health department.
D. Hospital Medical Records
Each hospital has its own rules for maintaining medical records. Most of these derive
from the standards set by the Joint Commission, which provide a detailed guide to
keeping records. Medical care practitioners who practice in hospitals should become
familiar with these rules. Under recent regulations from the OIG, hospitals are now
required to audit chart entries to assure that they meet the standards for
Medicare/Medicaid billing. These regulations also extend to outpatient clinics run by
the hospital, or in which the hospital has an interest. Unlike failure to comply with
Joint Commission medical records rules, which usually only merits a slap on the wrist,
failure to comply with Medicare/Medicaid rules will require the facility to dismiss the
medical care practitioner or face federal fraud charges on the bills submitted for
improperly documented care.
E. Electronic Medical Records
For more than 30 years electronic medical records have been the holy grail of medical
informatics. In the last few years they have become a practice reality and their use will
increase dramatically over the next decade. Electronic records offer quick retrieval,
compact storage, and the ability to aggregate huge amounts of medical data to look for
trends and statistical correlations.
There are four major hurdles to the effective use of electronic medical records. The
first is that they demand highly structured input if the output is to be useful. This is not
unique to electronic records, it is just that the expectations are higher. Everyone who
does research in traditional paper records quickly learns that the data are very difficult
to retrieve and require a sophisticated review to decipher and code into standard format
so they can be analyzed. There is an expectation that data in electronic records will
automatically be in a standard form for searching and use, even if the medical care
practitioners who use the electronic records type in the same stuff they hand-wrote or
dictated into the paper records.
The second problem is getting the medical care practitioners to complete the electronic
records properly. This is deadly work for those who do not type because there is only
so much you can do with checkboxes. Paper records, especially dictated ones, are
easier, especially because there is no electronic nanny making you really enter all the
data. This will only be solved by time and the demand that all medical care
practitioners learn how to type.
The third problem is that electronic records are especially easy to alter or otherwise
manipulate, unless they are designed to make this impossible. They are also
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