THE LEGAL AND ETHICAL ASPECTS OF MEDICAL RECORDS

The Legal and Ethical Aspects of Medical Records

The Legal and Ethical Aspects of Medical Records

Introduction

A medical record, medical chart or health record is a methodical documentation of a patient's medical history plus care. The phrase 'Medical record' is employed both for the physical folder for every individual patient and for the body of information which includes the total of every patient's health account. Medical records are intensely private documents and there are many ethical and legal matters surrounding them for example the degree of third-party rights to approach and appropriate storage plus disposal.

Legal matters of confidentiality over the Internet are still being debated. There are a number of matters, more of an ethical rather than technological concern, which call for addressing before technology opens Pandora's box.

The requirement of Rights to approach: One of the ACM guiding principles in the Code of Ethics states, "Avoid harm to others". The question of rights to approach must be considered in light of this principle. The requirement for rights to approach to a patient's records by medical professionals is fairly obvious. One might successfully argue that the modern hospital simply could not operate without its computerized record keeping systems, still ignoring the use of computer systems for diagnostic procedures (Braly, 2006).

The Provision of Rights to approach: The ACM Code advises "Contribute to society and human well being". This axiom is a good guide for queries on providing rights to approach. Queries of how we might provide such rights to approaches are quickly being answered. At one time, it appeared that the course to chase would be that of a national medical records folder.

The Restriction of Rights to approach: ACM's code also states, "Rights to approach computing and communications resources only when authorized ...