American Medical Association Opinion5

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Answer 1

Proper procedure indicates that yes -- it usually should be. Corrections in insignificant things such as spelling are of course less critical, but anything emergent to timely needs to show. Any changes to a medical file (hard copy) could not be covered over, as in whited out or inked out, but could only have a single line going. (Ehrlick 102)

Answer 2

On AMA the patient and physician should be advised about the existence of computerized data both before and information is stored.

Answer 3

Procedures for purging the computerized database of archaic or inaccurate data should be established and the patient and physician should be notified before and after the data has been purged.

Answer 4

The computerized medical database should be on-line to the computer terminal only when authorized computer programs requiring the medical data are being used. Individuals and organizations external to the clinical facility should not be provided with on-line access to a computerized data base containing identifiable data from medical records concerning patients. (Ehrlick 23)

Answer 5

The utmost effort and care must be taken to protect the confidentiality of all medical records, including computerized medical records.

The guidelines below are offered to assist physicians and computer service organizations in maintaining the confidentiality of information in medical records when that information is stored in computerized data bases:

(1) - Confidential medical information should be entered into the computer-based patient record only by authorized personnel. Additions to the record should be time and date stamped, and the person making the additions should be identified in the record.

(2) - The patient and physician should be advised about the existence of computerized data bases in which medical information concerning the patient is stored. Such information should be communicated to the physician and patient prior to the physician's release of the medical information to the ...
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