patient record

patient record

Patient medical record A document relevant to Pt management–eg, medical Hx, chief complaint(s), diagnostic and therapeutic procedures performed and current status, usually arranged in chronologic order. See SOAP.
McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc.

Patient discussion about patient record

Q. ex-wife works in hospital and accesses my and my familys medical records what can i/we do about this legally this is done without any consent she has computer acess to any records and accesses them upon her own

A. If you are sure of this she is breaking the law...Hippa protects patient right and this is a clear voliation of those right. I suggest you get a copy of the hospitals Right to Privacy , HIPPA paperwork. Then If you can prove this write a letter to hospital admenistration and one to her supervisor and/or director. Let them know you know this is a violation of patient rights and you want it dealt with immediatly or you will seek out legal council. They should responded to your letter in avery timely matter. If you do not have proof discuss with someone in medical record about the "need to know" bases and if ther eis no reason for her to know this information( she could be one tha thas to put it on your records) you would like to be assured she has no access to them and if she is doing a job that would give her the right ask that they please have someone else in the department handle you and your family dure to personal reasons. I encourage you to handle this in a very proffesi

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References in periodicals archive ?
As originally adopted, the SAMHSA regulations required any disclosure of a patient record made pursuant to patient consent to include a lengthy written notice about the prohibition on re-disclosure.
"It was in this same year that the Informing Healthcare strategy was launched, with an electronic patient record for Wales at its heart.
(1.) PR Newswire, Improving Provider Interoperability Congruently Increasing Patient Record Error Rates, Black Book Survey.
Manchester practitioner who falsified a patient record has been issued with a year-long suspension order
Ortivus AB (STO:ORTIB), a provider of patient monitoring system for ambulances and hospitals, announced on Thursday that it was informed by the West Midlands Ambulance Service NHS Foundation Trust of the approval of Ortivus' tender submission regarding a framework agreement for the supply of an ambulance electronic patient record system and the award of a framework contract.
As part of the deal, Cleardata will index each patient record and apply barcodes, so each record can be identified by patient number, name, NHS number, system number, date of birth, file number and service.
Even patient record covers, being manila folder thickness, can be fed directly into the scanners and digitised.
One example of a patient record card written by Dr Urquhart written solely by him involved a patient who first saw the doctor one week after birth in 1981 and the record continued until 1996, which gave a continuous developing picture of the patient's health [58].
An electronic health record or otherwise known as the electronic patient record has changed the whole concept of gathering health records of patients.
Kay Jeynes, head of district nursing in Cardiff and the Vale of Glamorgan, said: "The development of the electronic patient record in Cardiff and the Vale has been very much driven by staff and we have always wanted to have a mobile solution.
R3094042, issued by the General Services Administration (GSA) on behalf of the Department of Veterans Affairs (VA) for information technology (IT) services to support VA's Computerized Patient Record System (CPRS).

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