CHAPTER SIX
LEGAL ASPECTS OF HEALTHRECORDS AND VAROUS ACTS RELATED TO THEM
Introduction
This chapter will describe how to analyze and interpret the regal requirements affecting health records and the various acts related to them. It will concentrate on confidentiality, ownership, security, and disclosure of information.
Learning objectives
The students should be able to:-
Analyze and interpret legal aspects concerning;
Confidentiality
Disclosure
Ownership
Retention
Security
Consent of operation
Medical Records Ethics
Confidentiality
Information concerning patient is confidential and should not be released to any unauthorized persons. If a member of hospital staff improperly discloses any information concerning a patient where by the patients suffers material loss, the patient can easily sue the hospital and the officer who is in breach of his duty had made any improper disclosure. If a hospital authority is to minimize its risk in the matter, it is suggested that it should have a rule for strict secrecy about all the information regarding the patients, their disease, their affairs, and the affairs of their families obtained by any officer in the course of his duties .Further it is recommended that:
No authorized information should be given concerning patients or former patients.
Apart from normal replies , and enquires concerning the progress patient’s illness is to be given
Except from instruction of the consultant.
(C ) Case notes are not produced to unauthorized members of staff.
Disclosure of information
There are five main categories under which contents of patients records can be disclosed:-
Consent by the patent which could be implied or expressed.
If there is order.
If the interest of the doctor or the hospital cannot be otherwise safeguarded
If the transference between hospitals, clinic or doctors in the name interest of the patients.
If there exist a higher duty than the private duty eg notification and infectious diseases, notification of births and deaths registration , and notification of poisons.
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