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Medical Records Technology

Fairfax Injury Lawyer Brien Roche Addresses Medical Records Technology

Brien Roche

Medical records technology is changing the practice of medicine. It is also changing the doctor patient relation. In the past when patients asked for a copy of their records they were looked at askance. Today many in the healthcare field encourage patients to maintain a copy for themselves. Not only to be informed but also to confirm the records are correct. This can be done with electronic access to records. With the Open Notes systems patients can see not only lab results but the full notes of their doctor.

Electronic Medical Records In Injury Cases

A key step in the review of any injury case is record review. Hospitals can receive incentive payments from the U.S. government for using electronic records. Within those records there is not only data but what is called metadata. This metadata are the fingerprints of who has touched the records.

Complete Records

In terms of getting complete records there are several things to be on the look out for:

1. Your request for records should include the private health information disclosure log. This is a required log setting forth what, when, where, and by whom the records have been disclosed. This will help you decide whether there are other records out.

2.If suit has been filed then you should ask for the query audit trail. This is also called the medical record review inquiry. This sets forth who has looked at the records and when they did so. Also it states for how long they were reviewed and whether a hard copy of the record was made. In addition it states what changes were made to the record.
3. All audits of the audit log. This will identify all interruptions in collection of audit data. In addition it will give an explanation of who interrupted audit data collection, why they did so and for how long.

Doctors Orders and Nurses Notes

4. Doctor’s orders within the chart can be a problem because they may be summarized by department. Sometimes in these capsules the info such as who made the order, its time and the nurse who noted it may not be included. If there are questions about the timing or validity of orders then you need to get the audit trail. This audit trail will include all additions, deletions, and changes to the orders.

5. The metadata may show what options the user is presented with before making changes to the record.  It will reveal what different diagnoses or “differential diagnoses” are given to a doctor. All of that metadata helps to show the complete picture. In other words who made changes, when they were made and why they were made.

6.Nurses notes also may be a problem. To figure out what they mean you may have to get the data dictionary from the hospital. This will define terms used in the records. In addition you may have to get the audit trail as to the nurses notes. This should allow you to identify the nurses that provided the care and when they provided the care. In addition it states when they recorded the info.

7. All providers who give drugs are required to sign or record their name. Also the nurse is required to confirm the medicine was given. These times need to be compared with other times that appear in the chart.

All Records Are A Must

8.Finally, you must obtain all records in whatever format, paper or electronic. That combined chart may indeed be the entire chart.

9. You can obtain records now through the Hi-Tech Act. This requires providers to produce the records at reduced cost and faster. They are produced in electronic format. A special HIPPA form must be used for this. Be aware of the 2016 21st Century Cures Act which was designed to prevent info blocking in the creation and disclosing of records. Call, or contact us for a free consult.

Proximity Card

10. If there is an issue in the case of where the doctor is at any time, then ask whether or not there is a proximity card.  That proximity card may be a feature of the hospital monitoring system.  It may be part of the doctor’s cell phone.  If such a card exists, then it will tell you where the doctor is in relation to the hospital at any time.

Medical Records Technology: Smart Phones

Smart phones can be a means for enhanced treatment. Biosensors can pick up blood pressure, breathing, heart rate, glucose level, brain waves and more. Some providers allow diabetics to connect glucose monitors to the patient’s computer. This produces data for the provider.

Messages to and from your doctor should be on secure channels. Anything of an urgent nature should be dealt with through an office visit. Likewise messages that are involved or that will involve much back and forth should be covered through an office visit. Call, or contact us for a free consult.

Medical Records Technology: Ask Questions

Being aware of what is in your medical records allows you to keep the doctor better informed. It also allows you to stay focused on the care plan. Sometimes in dealing with your doctor you may have to be the squeaky wheel. If the care plan does not make sense you need to question it. If the lab results don’t match the treatment plan you need to ask questions. Also if something about the care plan does not feel right then you need to say something.

Medical Records Metadata-It Is Part Of The Record

At least two Virginia judges have looked at the issue of disclosing metadata. They have decided that the patient has a right to review the entire record. Also the provider is required to disclose its log of activities in the patient’s records.

This data discloses not only who accessed the chart but also when they accessed the chart. In addition it states what they did while they had access. This type of info highlights false entries. Also any backdating of info would be disclosed through this info.

Medical Records Metadata-The Whole Truth

Merely printing the entire record is not enough. Metadata is lost when only printed. Instead what needs to be produced is the file in “read-only” electronic format. That allows the user to read the record and print it as seen fit.

These types of requests are most often made in medical malpractice cases. They can also be used in more routine cases. Routine crash cases may merit this type of disclosure if they involve a host of providers.

Medical records technology can help improve your knowledge base. Also it can improve the quality of care. A site that may be of help is nlm.nih.gov/medlineplus/healthtopics.html . Call, or contact us for a free consult.

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Medical Records Technology

Fairfax Injury Lawyer Brien Roche Addresses Medical Records Technology

Brien Roche

Medical records technology is changing the practice of medicine. It is also changing the doctor patient relation. In the past when patients asked for a copy of their records they were looked at askance. Today many in the healthcare field encourage patients to maintain a copy for themselves. Not only to be informed but also to confirm the records are correct. This can be done with electronic access to records. With the Open Notes systems patients can see not only lab results but the full notes of their doctor.

Electronic Medical Records In Injury Cases

A key step in the review of any injury case is record review. Hospitals can receive incentive payments from the U.S. government for using electronic records. Within those records there is not only data but what is called metadata. This metadata are the fingerprints of who has touched the records.

Complete Records

In terms of getting complete records there are several things to be on the look out for:

1. Your request for records should include the private health information disclosure log. This is a required log setting forth what, when, where, and by whom the records have been disclosed. This will help you decide whether there are other records out.

2.If suit has been filed then you should ask for the query audit trail. This is also called the medical record review inquiry. This sets forth who has looked at the records and when they did so. Also it states for how long they were reviewed and whether a hard copy of the record was made. In addition it states what changes were made to the record.
3. All audits of the audit log. This will identify all interruptions in collection of audit data. In addition it will give an explanation of who interrupted audit data collection, why they did so and for how long.

Doctors Orders and Nurses Notes

4. Doctor’s orders within the chart can be a problem because they may be summarized by department. Sometimes in these capsules the info such as who made the order, its time and the nurse who noted it may not be included. If there are questions about the timing or validity of orders then you need to get the audit trail. This audit trail will include all additions, deletions, and changes to the orders.

5. The metadata may show what options the user is presented with before making changes to the record.  It will reveal what different diagnoses or “differential diagnoses” are given to a doctor. All of that metadata helps to show the complete picture. In other words who made changes, when they were made and why they were made.

6.Nurses notes also may be a problem. To figure out what they mean you may have to get the data dictionary from the hospital. This will define terms used in the records. In addition you may have to get the audit trail as to the nurses notes. This should allow you to identify the nurses that provided the care and when they provided the care. In addition it states when they recorded the info.

7. All providers who give drugs are required to sign or record their name. Also the nurse is required to confirm the medicine was given. These times need to be compared with other times that appear in the chart.

All Records Are A Must

8.Finally, you must obtain all records in whatever format, paper or electronic. That combined chart may indeed be the entire chart.

9. You can obtain records now through the Hi-Tech Act. This requires providers to produce the records at reduced cost and faster. They are produced in electronic format. A special HIPPA form must be used for this. Be aware of the 2016 21st Century Cures Act which was designed to prevent info blocking in the creation and disclosing of records. Call, or contact us for a free consult.

Proximity Card

10. If there is an issue in the case of where the doctor is at any time, then ask whether or not there is a proximity card.  That proximity card may be a feature of the hospital monitoring system.  It may be part of the doctor’s cell phone.  If such a card exists, then it will tell you where the doctor is in relation to the hospital at any time.

Medical Records Technology: Smart Phones

Smart phones can be a means for enhanced treatment. Biosensors can pick up blood pressure, breathing, heart rate, glucose level, brain waves and more. Some providers allow diabetics to connect glucose monitors to the patient’s computer. This produces data for the provider.

Messages to and from your doctor should be on secure channels. Anything of an urgent nature should be dealt with through an office visit. Likewise messages that are involved or that will involve much back and forth should be covered through an office visit. Call, or contact us for a free consult.

Medical Records Technology: Ask Questions

Being aware of what is in your medical records allows you to keep the doctor better informed. It also allows you to stay focused on the care plan. Sometimes in dealing with your doctor you may have to be the squeaky wheel. If the care plan does not make sense you need to question it. If the lab results don’t match the treatment plan you need to ask questions. Also if something about the care plan does not feel right then you need to say something.

Medical Records Metadata-It Is Part Of The Record

At least two Virginia judges have looked at the issue of disclosing metadata. They have decided that the patient has a right to review the entire record. Also the provider is required to disclose its log of activities in the patient’s records.

This data discloses not only who accessed the chart but also when they accessed the chart. In addition it states what they did while they had access. This type of info highlights false entries. Also any backdating of info would be disclosed through this info.

Medical Records Metadata-The Whole Truth

Merely printing the entire record is not enough. Metadata is lost when only printed. Instead what needs to be produced is the file in “read-only” electronic format. That allows the user to read the record and print it as seen fit.

These types of requests are most often made in medical malpractice cases. They can also be used in more routine cases. Routine crash cases may merit this type of disclosure if they involve a host of providers.

Medical records technology can help improve your knowledge base. Also it can improve the quality of care. A site that may be of help is nlm.nih.gov/medlineplus/healthtopics.html . Call, or contact us for a free consult.

Contact Us For A Free Consultation

Contact Us For A Free Consultation