Transcript Patient Rights and Medical Records: a JCI Perspective

Patient Rights, Medical Information
Records: a JCI Perspective
&
October 10, 2007 Makati Medical Center
ATTY.
RODEL V. CAPULE
Professor
&
MD FPCEMAC FPCP
Consultant, Legal Medicine
Objective
To familiarize all physicians on the
provisions of JCI related to patient’s right
to privacy, medical records and medical
information.
 To understand patient’s right to privacy
and confidentiality of health information.
 To understand the legal issues related to
medical records.

Standard PFR.1.6

Patient information is confidential.
Intent of PFR.1.6
Medical and other health information is
important for understanding the patient
and his/her needs and for providing care
and services.
 Medical and other health information is
documented:
1. in paper form
2. in electronic form
3. or combination of the two

Duties of the hospital
Respects medical and other health information
as confidential.
 Implements policies and procedures that protect
such information from loss or misuse.
 The policies and procedures reflect information
that is released as required by law and
regulations.
 The hospital has a policy that indicates if
patients have access to their health information
and the process to gain access when permitted.

Duties of staff
Aware of laws and regulations governing
confidentiality.
 Inform the patient about how the hospital
respects the confidentiality of information
 Patients are informed about when and
under what circumstances information
may be released and how their permission
will be obtained.

Respect for patient confidentiality
Not posting confidential information on
the patient’s room.
 Not posting confidential information at the
nursing station.
 Not holding patient-related discussions in
public places.

Definition
Right to Privacy
 Duty to respect Confidentiality
 Duty to breach Confidentiality
 Privileged communication

Right to Privacy
Right to be left alone.
 Owned by the patient.
 No person can access any information
about a patient without his consent.

Duty to respect confidentiality
Duty is imposed on the health care
provider. (includes the hospital)
 All information should be kept secret by
the physician, even those acquired from
other parties.
 Promotes truth telling on the part of the
patient.

Duty to breach confidentiality

Reportorial duty of health care provider

Impose by law-
Act 3573 “Law on Reporting of Communicable
Diseases” (1929); PD 169 as amended “Requiring Doctors, Hospitals, Clinics, etc. to
Report Treatment for Physical Injuries” (1987) ; PD 603 “…reporting of child abuse
case within 48 hours”
Exercise of police power- public health
protection
 Protection of third parties- Tarasoff v. Regents of

University of California 131 Cal.Rptr 14 (1976)
Privileged Communication

Rule of admissibility
(Rule 130 sec 24 (c) Rules of Court)
Disqualification by reason of privileged communication – The following
persons cannot testify as to matters learned in confidence in the following
cases:
(c) “ A person authorized to practice medicine,
surgery, or obstetrics cannot in a civil case,
without the consent of the patient, be examined
as to any advice or treatment given by him or
any information which he may have acquired in
attending such patient in a professional
capacity…”
Release of medical information
Release during confinement:
- queries from relatives, friends, media,
police authorities.
 Release after confinement:
- patient, authorized representatives,
police authorities, insurance companies,
courts

Directory Information
Name
 Location
 Medical status
 Religion

Requirement before release of
directory information

The first and last name must be recited by
the asking party.

Consent of patient.
Release of Location

Should not be released if it would
embarrass the patient.
Release of AP’s name
Case to case basis.
 Not advisable if specialty practice of AP
would embarrass the patient.

Release of medical records to
other parties
General rule: should be released only
to the patient himself
 Release to other party:
- authorization from the patient
- only relevant records

Release via fax/e-mail
Record the phone number or e-mail
address on the chart.
 If by fax, specify what time it should be
sent.
 Specify if it can be receive by other
persons.

Who owns the medical record?
The physical medical record/chart (includes all
diagnostic films, slides, tracings, reports etc.) is
owned by the hospital.
 Ownership interest on the information:
1. hospital
2. physician
3. patient
4. insurance company
5. courts
6. police authorities

Hospital Medical Records Management
Manual DOH 2nd ed. 1994

“For medical records ownership is not
absolute, because the patient also has a
right to the information written on the
record, that being his health history.”
- Chapter 6 page 67
Who can write entries in the
medical chart?
Hospital determines who can write in the
medical chart.
 Licensed healthcare provider
 Interns, medical students (?)

Department of Medical Records

Duties:
1. custodian
2. protects the record from the elements
3. protects the record from pilferage, loss
and misuse
4. destruction of records
5. certifies duplicate copies
Right to access the medical chart
during confinement
Access is granted within a reasonable
time.
 Chart must be complete.
 Patient must not be left alone with the
chart.

Right to access medical chart
after confinement
Access is granted within a reasonable
time.
 Chart must be complete.
 Patient must not be left alone with the
chart.

Medical record entries
Legible and complete medical record
entries.
 Timely medical record entries.
 Authorship and countersignatures.
 Authentication of records/autoauthentication.
 Verbal orders.
 Corrections and alterations.

Admissibility of medical records
Rule 130 sec. 43 (RRC)
Can be received as prima facie evidence even if
the person is deceased or unable to testify.
 Requirements:
1. entries made at, or near the time of
transactions to which they refer.
2. person was in a position to know the facts
there in stated.
3. entries made in his professional capacity or in
the performance of a duty.
4. entries made in the ordinary or regular course
of business or duty.

The End