Medical Law and Ethics
The significance of medical records may go unnoticed as the migration from paper medical records to digital health records takes center stage in discussions regarding medical records currently. Medical records, whether in electronic or paper form, play a critical role in patient care and are useful to not only the patient but also the physicians and professionals. As the only source of written information about what actually transpired between the patient and the healthcare provider, the medical record holds ethical and legal significance to all stakeholders in the provision of care especially doctors, professionals and patients.
Physicians need medical records to provide better and appropriate treatment to the patient. Medical records enable doctors to know the type of medications that adversely affect the patient and thus avoid prescribing such medications (Breen 87). Not all drugs meant for treating a certain disease would produce the intended results on the patients. Some patients may be allergic to some of these drugs and the doctor should be the first person to have such knowledge. Only the medical record would enable the physician to identify the medications that might trigger such allergies. Once the physician discovers the possibility of such negative effects, he or she can prescribe alternative treatments or alternative drugs to minimize the unintended unfavorable effects.
In addition, physicians are better placed to advise the patient on how to prevent infection. Some patients are more vulnerable to some diseases due to biological, environmental, or other factors. By examining the medical record, the doctor can easily detect such dispositions and advise the patient accordingly (Roach, 33). Further, the medical record can be extremely valuable to the physician in emergency cases in which the patient is unconscious or unable to express himself or herself. While the physician can seek information about the patient from caregivers and family members of the patient, such information may not be accurate and complete and thus cannot be authoritative. Even in situations where the patient can be interviewed to learn about his or her medical history, oral reports are prone to errors since the patient has to rely on his or her memory. Therefore, the medical record is the most reliable source of information about the patient’s health not only in emergency cases but also in all treatment situations.
Medical records are crucial for other professionals concerned with patient care including hospital staff and law professionals. Nurses play a critical role in patient care by administering medication and other treatment modalities on a daily basis (Breen 87). This cannot be done without the daily orders available in medical records. Proper medical records can be very useful in medical legal cases. Physicians need medical records to prove their innocence when charged with negligence (Roach, 33). For example, when a patient is given a drug that produces severe allergic reactions, the doctor or the nurse or both can be charged with negligence. If the physician indicates in the medical records that the particular drug is allergic and thus should not be used, but the nurse ignores such a note, then the nurse may be found guilty of negligence. If the doctor knows that the patient is allergic to certain drugs but fails to indicate that in the medical records, the doctor might be held responsible in case the patient develops complications related to the drug.
To the patient
Medical records are important to not only the physicians and professionals but to the patient as well. To start with, patients who take keen interest in compiling and storing their own medical records are more conscious of their own health than those who wait to see the physician. Awareness of one’s health status is important for the patient because it puts the patient in a better position to prevent some illnesses especially allergic reactions. Patients who experience allergies should understand their causes and strategies for preventing them. With such understanding, they can play a more active role in choosing appropriate treatments for their conditions and thus be helpful to physicians. In addition, medical records enable patients to continue receiving appropriate care regardless of their geographical location (Iyer and others 4). When the patient moves to another hospital or changes doctors, the new physician can continue caring for the patient without difficulties as long as he or she has access to the patient’s medical record. Further, medical records ensure patient safety by acting as the most important source of evidence in medical malpractice cases. Patients who develop complications following treatment can be compensated if proof of physician’s negligence is obtained (Roach, 33). Only medical records can provide such proof. Disputes between health care providers and patients over care are not a rare occurrence. In such cases, medical records provide the patient with legal protection against any form of harm or abuse of patient’s rights.
In summary, medical records enable the physician to provide appropriate care to the patient and prevent medical legal suits arising from negligence. Professionals such as nurses need medical records to provide appropriate care to patients on a daily basis. In case of medical malpractice suits, law experts need to examine medical records to prove negligence by physicians or other health care providers. To the patient, medical records ensure continuity of care and offer protection against inappropriate care that could otherwise result to complications and even death.
Breen, Kerry J. Good Medical Practice: Professionalism, Ethics and Law. Cambridge: Cambridge University Press, 2010. Print.
Iyer, Patricia W, Barbara J. Levin, Mary A. Shea, and Kathleen Ashton. Medical Legal Aspects of Medical Records. Tucson, AZ: Lawyers & Judges Pub. Co, 2006. Print.
Roach, William H. Medical Records and the Law. Sudbury, Mass: Jones and Bartlett Publishers, 2006. Print.