When a patient visits a doctor’s office, various aspects of the visit are recorded by the health care providers – some of which is mandated by law. Over a person’s lifetime the information recorded during these encounters accumulates in a patient’s medical records. Health care professionals utilize the medical records to maintain both the case history of the patient and to plan for future patient care. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) defined standards for the protection and access of this sensitive information. Learn more about patient medical records by viewing the resources listed below.
Overview
Information recorded in the medical record includes histories of surgical procedures, immunizations, family history, medications and allergies. For each medical encounter, vital measurements such as temperature, blood pressure, pulse and respiratory rates are recorded. The health care provider will document any diagnoses and perscribed treatments.
Privacy Protections
A patient’s medical history can contain very sensitive information. Health care providers are obligated to only share this information with qualified professionals involved in the care of the patient. In the age of electronic health records, however, fulfilling this obligation is much more complex. Without proper controls, patient data can be accidentally or maliciously distributed to a wide range of unauthorized people.
- Medical Privacy in the Electronic Age
- The HIPAA Privacy Rule
- HIPAA And The Privacy Of Your Medical Record
- Electronic Privacy Information Center (EPIC)
Specific Security Measures
HIPAA defines standards and procedures for securing electronic health care data. These include administrative processes, technical controls, and physical measures designed to make data accessible to only health care workers that have a reason to work with it.
- The HIPAA Security Rule
- A Framework for Exchange of Individually Identifiable Health Information
- Medical Record Privacy, Security and Electronic Transactions
Ethical Concerns
While HIPAA establishes specific standards for the format and availability of electronic medical records (EMRs) and unfortunate precedent exists for entities which are authorized to access a patient’s records to use the information for purposes which are not in the patient’s best interests. It is for this reason that ethical considerations play a strong role in the management of medical records.
Patient’s Rights
Patients receiving medical care are guaranteed certain rights to their medical information by federal and state governments. Examples include the right to obtain a copy of your medical record and to keep those records private. These rights are generally explained by providers as a matter of policy and procedure.
- Patient’s Bill of Rights
- What are my Rights as a Patient?
- Mental Health Bill of Rights Project
- Patient Rights and Responsibilities
The Personal Health Record
Health care providers compile and maintain the medical records for each of their patients. However it is becoming increasingly common for patients to create their own Personal Health Record (PHR). This medical information is maintained by the patient, and is often stored electronically or in physical format carried on the person. The PHR can be useful in improving communication between patient and health care provider, as well as being more accessible by the patient, and by medical personnel in the event of an emergency.
