A health record technician has brought a patient’s record to the attention of th

Question

A health record technician has brought a patient’s record to the attention of the HIM director because the technician feels there are some suspicious sections in the record where the physician did not document certain treatments or purposes for treatment which may have led to an adverse outcome suffered by the patient. The HIM director has reviewed the record and agrees with the technician that a potential adverse event may have occurred. Subsequently, the physician recognizes he should have been more specific in documenting the patient’s care. He is now asking the HIM director, who is a personal friend, to let him add additional documentation to the patient’s record, which has since been placed on legal hold. 1 Since the director is a friend of the physician and knows he should have been more specific in his documentation, should the HIM director allow the physician access to the record to add the documentation? Why or why not? 2. If the HIM director did give the physician access to the record, what ethical issues does this decision raise?

Explanation / Answer

1. The HIM director can allow the physician friend to make a proper documentation as a physician can understand what actually happened to the patient. If there is anything missing in the report then they can recheck the patient's condition to make the documentation perfect.

2. In that case, maybe there some ethical issues can be happened such as the autonomy of the patient, confidentiality and privacy of the medical report, training and reasoning regarding clinic and so on. there are so many people who want to keep secret about their report. If the director takes help to make a proper documentation then there will no confidential state of the report. some patient doesn't like this. this may occur some inconvenience between patient and health check-up organization.

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