patients/medical records/doctors? what is the rules/law

[S.Wilsford]

What is the name of your state? Texas
Can anyone tell me when it comes to a patients, in office. medical records, what the rules/laws are concerning what and how much information they should contain?

 

[ellencee]

No.
No exact requirement is 'law'.

Each office has its own policies and procedures for documentation.

Why?

 

[S.Wilsford]

so doctors have no legal obligation to their patients as to what type of information, findings, recommendations, etc., is kept by their office? Do they have to keep any at all? I suppose it goes unsaid that it is a good idea to get copies of what records they do have as often as possible.
What about surgical reports? Is it required they fill out the pre and post-operative diagnosis section?

 

[JackSchroder]

The records the doctor makes for his treatments of his patient, belong to the patient. This matter is poorly understood by the medical profession. You have an absolute right to see your records and to have copies of them. If your doctor has written poor records, you have a right to ask for clarification. Many doctors in their arrogance feel they do not have to write records that can be read, but Medicare and Medicaid both require complete, legible records. That means they must be readable. You may find, especially in a state like Texas, that doctors "refuse" to allow patients to see their own records. In that case, you may need to go to a lawyer who can demand the records. By definition a doctor is the custodian of the patient's records, he is not the owner.
Think of your records in tbis way: When a doctor performs any treatment on you, he records his treatment so you, the patient, may be able to inform your next doctor/hospital what has been done to you in the past. For instance, when you buy insurance from a broker, that broker supplies you with a written copy of what your insurance promises. If you ask a contractor to plan an addition to your home, he makes a drawing of his proposal, and often specifications. This is not so he knows what to do next, but so you have a written record of what he proposes to do, and by the way, so the building department of your city also knows what he plans to do. Making a record is part of the job you pay for. It is not separate.

 

[ellencee]

Jack
I do not think you should continue to tell these posters that medical records belong to the patients when the courts have ruled over and over that the records belong to the medical provider and that the patient has a right to see the records in certain circumstances.

You are neither a medical professional nor a legal professional and I do not believe it is in the best interest of the posters for you to continue to provide them with false information.

Medical records are written by the provider and for the provider, not for the patient, not for the legal community. Medical records are the property of the provider. For it to be any other way, it would be chaos.

I have asked you to provide a legal ruling that contradicts the legal rulings that I have posted that clearly state the courts have ruled that the medical records belong to the providers and you have not posted any. Either provide the documentation to support your claim or quit providing these posters with incorrect information about their medical records. I believe it is a serious disservice to the posters to lead them astray.

EC

 

[ellencee]

S.Wilsford

so doctors have no legal obligation to their patients as to what type of information, findings, recommendations, etc., is kept by their office? Do they have to keep any at all? I suppose it goes unsaid that it is a good idea to get copies of what records they do have as often as possible.

You are mixing apples and oranges. Of course, physicians have a duty to their patients to maintain proper records of tests and treatments. The method of doing so is not universal. Each provider has a method that works for them and is within acceptable standards for maintaining records. Some use a method that I consider to be horrendous, but it is an outcome of frivilous lawsuits and the public attitude that seeking medical care is akin to buying a lottery ticket. That particular method of documentation is known as documentation by exception and means if nothing is out 'normal' then nothing is documented.

Anyone with a chronic illness or medical condition should have a copy of pertinent medical information on them at all times. That can be and should be a copy of their latest physical exam and prescribed treatments. Otherwise, it is foolish to have a copy of one's medical records. Most people absolutely do not understand the information in medical records or the significance of any information in them, including tests. If it were otherwise, you could simply have your next door neighbor do your physical exams and tell you what is wrong with you.

I assure you, if I was wrong in telling you that you have no basis for a further lawsuit, including an appeal, one of the attorneys would have corrected me. I depend on their doing so, as does this site.

I would very much appreciate your telling me the type of surgery that you had. I would like to research this procedure to gain knowledge about it and it may provide me with an opportunity to help you understand why the verdict in your trial was not in your favor.

What about surgical reports? Is it required they fill out the pre and post-operative diagnosis section?

Well, policy and procedure probably requires doing so, but it does not constitute negligence or malpractice for those sections to be left blank. The information is included elsewhere in the records.

Best wishes,
EC

 

[S.Wilsford]

He failed to record information concerning tests, findings, diagnosis, intentions(other than stating he will perform surgery) or any type of name for the condition requiring surgery, not only on the surgical reports, but on any records. The name of the surgery is "Bristow Procedure". It was created in hopes of stabilizing the shoulder from anterior dislocations, from what I have read and heard from shoulder instability specialists, due to complications relating to the screw used, this surgery was long ago considered a last resort procedure and is now listed in shoulder books for historical reasons only. Not only is it not recommended for the repair of anterior dislocations, it was at no time a suggested surgery for someone with multi-directional shoulder dislocations/instabilities, which is what I have. This doctor performs this procedure numerous times a year and supposedly if you called 100 Orthopedic surgeons and inquired as to how many Bristow procedures they perform in a year 10 of the 100 may have performed 1. I have copies of all of my medical records and possession or rights to possession of them is not an issue, it is the information, or lack there of, that I have a problem with along with the fact this doctor is allowed to continue performing this particular procedure. Just because he did not loose the malpractice suit should in no way allow him to continue using a procedure which was adequately proven in court as no longer suggested for use for any shoulder condition. Is there a way to find just how many of these procedures he has done in say a five year period?

 

[JackSchroder]

The best research tool on the internet can be found by typing keyword: MEDLINE.
This takes you to the most complete medical library in the US of A.
Look up the Bristow thing, and also look up your doctor to see if he has ever written a paper. You may not find out from this how many procedures he has done. I'm not sure you can unless you file suit and your lawyer deposes him and asks him that quesytion.
If you think the hospital might give you and honest answer, ask. Don't ever expect the truth from a hospital.
Another thing you might do is go to your local courthouse and look up malpractice lawsuits against both the hospital and that doctor. You may find something this way. If you find a case against that doctor, go see the doctor who tried it, win or lose. Or ask malpractice lawyers in your area what they have found out about this guy. They may help, but that's an outside shot.
I don't think you local medical society will answer your questions. The medical doctor licensing board probably has no information.

 

[summerbreeze65]

Medline is a wonderful website! Use it often.
~Summer~

 

[pele]

I could not find Bristow procedure on Medline, but thanks for a link to a good site Jack. If you go to Google and type Bristow prodedure in the search box, a lot of links show up. I will leave the rest of this to Ellencee and sign off before I get knocked of IE AGAIN.

 

[S.Wilsford]

Jack
I do not think you should continue to tell these posters that medical records belong to the patients when the courts have ruled over and over that the records belong to the medical provider and that the patient has a right to see the records in certain circumstances.

You are neither a medical professional nor a legal professional and I do not believe it is in the best interest of the posters for you to continue to provide them with false information.

Medical records are written by the provider and for the provider, not for the patient, not for the legal community. Medical records are the property of the provider. For it to be any other way, it would be chaos.

I have asked you to provide a legal ruling that contradicts the legal rulings that I have posted that clearly state the courts have ruled that the medical records belong to the providers and you have not posted any. Either provide the documentation to support your claim or quit providing these posters with incorrect information about their medical records. I believe it is a serious disservice to the posters to lead them astray.

EC

I do not know about everywhere else, but in Texas, doctors are required to keep a patients medical records for I believe it is a period of 7 years UNLESS the records contain any medical information, procedures, etc. which resulted in any change in anatomy and then they are to keep them as long as they practice. Their sole purpose is as a reference for the patients and their future medical providers concerning medical history, but unless requested, using a signed medical release, by the patient or by a physician treating the patient, at which time a copy is then sent to the new doctor at no charge, OR by the patient for their personal records, for which there is a charge set by the doctors office for providing copies of medical records, Medical Records are property of the Doctor.

 

[S.Wilsford]

The best research tool on the internet can be found by typing keyword: MEDLINE.
This takes you to the most complete medical library in the US of A.
Look up the Bristow thing, and also look up your doctor to see if he has ever written a paper. You may not find out from this how many procedures he has done. I'm not sure you can unless you file suit and your lawyer deposes him and asks him that quesytion.
If you think the hospital might give you and honest answer, ask. Don't ever expect the truth from a hospital.
Another thing you might do is go to your local courthouse and look up malpractice lawsuits against both the hospital and that doctor. You may find something this way. If you find a case against that doctor, go see the doctor who tried it, win or lose. Or ask malpractice lawyers in your area what they have found out about this guy. They may help, but that's an outside shot.
I don't think you local medical society will answer your questions. The medical doctor licensing board probably has no information.

Reply to JackSchroder from S.Wilsford:
This guy was apparently unable to write my medical records, I seriously doubt he is or has ever been capable of writting a paper. Or do they have some type of "hacker" award?

Is information concerning medical malpractice suits, no matter the end result, public record? If so, who do I see at the courthouse for this information?
The Texas Medical Examiners Board only uses complaints against physicans that resulted in action taken by them or complaints waiting to be tried before the highest council, as public records. Either the Medical Examiners Board or the American Medical Association provide the above along with criminal record information and information about medical malpractice suits IF the suit was lost by the physician or if 3 or more alleged suits have been filed in a 5 year period.

 

[JackSchroder]

Courts are different in every state. But you go to the Clerk of the Court, or County Clerk for index to civil lawsuits. Usually these will be coded for injury, malpractice, contracts or whatever. Go through all those for malpractice. I made a mistake in my earlier note, you see the LAWYER (of course, not the doctor) and I have found lawyers are eager to talk about their cases and will sometimes allow you to read/copy depositions of the doctor. Depositions are sealed at the court house, but lawyers don't see any need to keep them confidential. I am talking about plaintiff's lawyer, of course.
Civil lawsuits are public.
Interesting that Texas says the doctor owns the records. But apparently when the old coot dies, a patient can obtain his records. That's good.

 

[ellencee]

S.Wilsford, et al
I've been researching the Bristow procedure and it apparently is a procedure that is a dismal failure to 9 out 10 patients. Yet, I find nothing that states that physicians should be professionally restrained from performing the procedure!
The amount of information I have gathered is daunting and will take me a while to make it through it all. Anyone else who is researching this and would like to compare notes, please email me at ellencee@hotmail.com.
Thanks,
EC

 

[ellencee]

S.Wilsford
He failed to record information concerning tests, findings, diagnosis, intentions(other than stating he will perform surgery) or any type of name for the condition requiring surgery, not only on the surgical reports, but on any records. The name of the surgery is "Bristow Procedure". It was created in hopes of stabilizing the shoulder from anterior dislocations, from what I have read and heard from shoulder instability specialists, due to complications relating to the screw used, this surgery was long ago considered a last resort procedure and is now listed in shoulder books for historical reasons only. Not only is it not recommended for the repair of anterior dislocations, it was at no time a suggested surgery for someone with multi-directional shoulder dislocations/instabilities, which is what I have.

You are correct in that he should have documented, somewhere, the physical findings that led to the diagnosis and the rationale for the surgery. If it is not in your medical records from his office, is it in the history and physical (H & P) in the hospital's records? the surgical report? Unfortunatley, he could have simply documented somthing like 'recurring anterior dislocation of right (or left) shoulder due to X' or something like that and been within minimum documentation requirements (depending on the applicable documentation standards).
Is it in the nurse's notes from the hospital admission procedure or the pre-op assessment by the nurses or the anesthesists?

EC