Legal Medical Record Standards - Policy: Fill & Download for Free

I don't know what this Medical record file is that you are talking about. If you mean the original hospital case file where they write the daily notes. I don't think there is any useful information that can be gleaned out if them since daily notes are not written in detail.The hospital is entitled to keep their original medical records to themselves as they need to document and medically audit case records. In case of some malpractice suits, the original medical records are the hospital/ doctor's only defense against frivolous claims.Medical record keeping has evolved into a science of itself. This will be the only way for the doctor to prove that the treatment was carried out properly. Moreover, it will also be of immense help in the scientific evaluation and review of patient management issues. Medical records form an important part of the management of a patient. It is important for the doctors and medical establishments to properly maintain the records of patients for two important reasons. The first one is that it will help them in the scientific evaluation of their patient profile, helping in analyzing the treatment results, and to plan treatment protocols. It also helps in planning governmental strategies for future medical care. But of equal importance in the present setting is in the issue of alleged medical negligence. The legal system relies mainly on documentary evidence in a situation where medical negligence is alleged by the patient or the relatives. In an accusation of negligence, this is very often the most important evidence deciding on the sentencing or acquittal of the doctor.The government of India has made it mandatory for all hospitals to keep their original medical records so it is understandable why it is so. With the advent of electronic medical records, many hospitals do not have any paper records. It has become easier for hospitals to maintain records safely. Hospitals also have the responsibility to share medical records with patients while keeping patient confidentiality.The Medical Council of India guidelines also insist on preserving the inpatient records in a standard proforma for 3 years from the commencement of treatment. The records that are the subject of medico-legal cases should be maintained until the final disposal of the case even though only a complaint or notice is received. It is necessary that the Government frames guidelines for the duration for which medical records are preserved by the hospitals so that hospitals are protected from unnecessary litigation in issues of medical records.However you can request the hospital management for a copy/Photocopy of the whole patient file at your own cost. Some records can run into hundreds and thousands of pages. That is your right but you have to pay for it. Just don't expect it for free.What will be useful to you would be a case report or a detailed discharge summary. You can request it from the hospital which may take a couple of days. Some hospitals may charge a fee but most give it for free. In my opinion you should ask this. Make a written request for a case report and take an acknowledgement stamped by their office staff.This is what the law says about patient confidentiality:Disclosure of personal health information is permitted and does not amount to a violation of privacy in the following situationsduring referral,when demanded by the court or by the police on a written requisitionwhen demanded by insurance companies as provided by the Insurance Act when the patient has relinquished his rights on taking the insurancewhen required for specific provisions of workmen's compensation cases, consumer protection cases, or for income tax authoritiesdisease registrationcommunicable disease investigationsvaccination studiesdrug adverse event reporting.If the hospital refuses to give you either the copy of the case file or the case report then you can complain to the state medical council which will take action against the concerned hospital. You can warn the hospital that you will complain which may make them change their mind. The hospitals would be very foolish to refuse sharing patient records after your warning.References:Medical records and issues in negligencePrivacy in Healthcare: Policy GuideA2A

Let’s take these point-by-point.“Unconstitutional orders have been signed…” That the courts have granted injunctions against executive orders isn’t generally considered a standard for impeachment. IIRC, President Obama’s immigration policy was enjoined by a federal court in Texas - did you call for his impeachment and removal then? If not, why not?“The President has threatened Members of Congress (AHCA)…” Oh, come on. He’s negotiating with Congress. LBJ used to physically bully Members when trying to get what he wanted, poking at chests and haranguing them endlessly. Let’s not get the vapors over nothing new.“Important files have not been released (tax returns, President’s medical records being reportedly falsified)…” There’s no federal law that requires either of these sets of records to be disclosed to the public. You may not like it - and certainly the idea of falsified medical records worries me as well - but you’re inventing legal standards if you think the President is obligated to publish either of those.“Posts have not been filled…” So that’s the Senate’s fault, right? Since Senate Democrats have forced delays in filling nominations? Why do you blame the President? And if you’re not referring to Senate-confirmed posts, the fact is that the President decides how to staff the Executive Branch. It’s assuredly not an impeachable offense that a White House official might not have been named.While the Constitution doesn’t define the criteria for impeachment in any specific terms - thus, technically speaking, the President can be impeached for anything that a majority of the House of Representatives thinks warrants impeachment - nothing that you’re outlining here is likely to rise to the level of impeachment, even if Democrats were to win the House back in the 2018 midterms.Thus to answer your final detail: no, there’s no precedent for removing the President from office for the perceived offenses you’ve listed. There’ll need to be something much more substantial for any House of Representatives, let alone a Republican-majority House, to consider articles of impeachment.He’s the President, and he’s likely to remain the President until at least 2021. You may want to start progressing to the fifth stage of grief here.

Doctors and dentists have a duty to properly document their interactions with patients. Now — if they get something wrong, they can amend a medical record, but let me qualify what is meant by “amending.” Amending doesn't mean deleting anything in the medical record. Deleting isn't permitted.Medical Records are legal documents. They must remain intact, even when it comes to errors. Doctors and dentists should be taught/instructed on how to amend a medical record to address an error(s). Deleting any information from a medical record isn't in compliance with federal and state regulations related to medical records, and may be a criminal act.“Updating” (documenting the latest information in) a medical record is not the same as “amending.” Updating a medical record is an add-on, and it may correct prior information noted in the medical record. But, it is not amending (minor changes to make more accurate) and it is not deleting (removing information).As I've noted in prior posts on the subject, the medical record belongs to the doctor's or dentist's practice, not the patient under state law. There are a number of federal and state regulations and industry standards (e.g., memorializations in payer policies) that dictate how the medical record must be maintained.To the question — I would not say it's “a right.” No. Additionally, patients have a right to add a statement to the medical record if they find information they disagree. Now — the statement is a supplement to the record. It's not an official statement of the doctor or dentist. It is part of the medical record, and doctors and dentists should allow it (even if absurd) for fairness, and document their response to such statement of they find it (or any part) objectionable.