Medical Records and the Law

Special Documentation Concerns 281general principle of patient autonomy as established by the New JerseySupreme Court in In re Quinlan, 39 where the constitutional right toprivacy was held to include a right to refuse medical treatment, and bythe U.S. Supreme Court in Cruzan. Finally, the county medical examinerdetermined upon autopsy that “no treatment could have remotelyimproved [Ms. Schiavo’s] condition.” 40Both the federal and state legislatures have responded to the need toformalize the decision-making process for competent and incompetentpatients who are faced with life-sustaining treatment decisions. As discussednext, legislation at the federal level imposes duties on healthcareproviders to inform patients of their right to accept or refuse medicaltreatment, and every state has some type of statute that regulates patients’right to specify, in advance of incompetency, what medical measuresshould be used to sustain their lives. Moreover, the JCAHOrequires all healthcare organizations to have policies and procedures regardingdecisions to forgo or withdraw life-sustaining procedures.Patient Self-Determination ActLegislation requiring that all federally funded facilities inform patientsof their rights under state law to accept or refuse medical treatment wasenacted as part of the Omnibus Budget Reconciliation Act of 1990,more commonly referred to as the Patient Self-Determination Act(PSDA). 41 Since December 1, 1991, when the PSDA took effect,healthcare providers and institutions that receive Medicare or Medicaidfunding have been required to inform patients of their legal right toaccept or refuse medical or surgical treatment, and the right to formulateadvance directives. 42 “Advance directive” is defined as a written instruction,such as a living will or durable power of attorney for healthcare, recognized under state law and relating to the provision of medicalcare when the individual is incapacitated. 43 Covered providers include,but are not limited to, hospitals, clinics, rehabilitation facilities,39In re Quinlan, 355 A. 2d 647 (N.J. 1976).40“Schiavo Autopsy Says Brain, Withered, Was Untreatable,” New York Times ( June 16,2005).41See Omnibus Budget Reconciliation Act of 1990, Pub. L. No. 101-508, 104 Stat. 1388,codified at 42 U.S.C. § 1395cc(f ).4242 U.S.C. § 1305(b)(1)(a)(1)(A)(i).4342 U.S.C. § 1395cc(f )(3).