Medical records, access

K. D. Mandl, P. Szolovits, and I. S. Kohane. 2001. Public standards and patients control How to keep electronic medical records accessible but private. British Medical Journal 322 283-287. 

Medical Records Access to Medical and Exposure Records (OSHA 3110— 2001). 

OSHA. 1982. Access to employee exposure and medical records proposed modification request for comments and notice of public hearing. Occupational Safety and Health Administration. Federal Register 47 30420. 

Occupational Safety and Health Administration (OSHA). (1986). Administrative Rule concerning OSFLA access to employee medical records. 29 Code of Federal Regulations (CFR) Part 1913. 

AU the medical records of the subject should be available for comparison with the data recorded in the case report form (CRF). In the past, physicians have not allowed medical records to be available for the so-called source verification by non-physicians since they felt that this broke the strict confidentiality of the study subject s medical records. However, frequent mistakes in transferring important clinical data to the CRF, the recruitment of subjects who do not meet the inclusion and exclusion criteria and the occasional blatant fraud has led to an insistence by sponsors and regulatory agencies for sponsor s review of study documentation. Indeed, verification of source data cannot take place without access to the medical records of the study subject by the sponsor s staff. 

Direct access to source data/documents AU medical records available... 

Complete access to the patient s medical information (i.e., the medical record)... 

Occupational medical records should record and document occupationally related medical information of all types (e.g., medical examinations, visits to medical facilities [even for nonoccupational reasons], clinical laboratory data, injuries, pulmonary function tests, audiograms, etc.). The period of time that records must be retained is specified by law depending on the type of data and the health-related agent(s) of concern. In most cases, OSHA requires that information be retained for at least 30 years after the termination of employment (OSHA Standard 29 CFR 1910.1020 Access to Employee Exposure and Medical Records). Medical records should be kept in compliance with the OSHA... 

A survey conducted by the Medical Records Institute in 2002 on health care practitioners concerns with the implementation of mobile technology devices and applications cited security/confidentiality when sending or receiving information and the lack of Health Information Portability and Accountability Act (HIPAA) compliance as primary concerns by 50 and 34 percent of respondents, respectively. Confidentiality and security of information against unauthorized access must be HIPAA-compliant. A number of systems are available that can help a pharmacy organization to remain in compliance with HIPAA regulations. Pharmacists are required by law to use reasonable methods to ensure that protected health information remains... 

The guideline specifically states that an explanation of the subject s responsibilities must be referenced during the informed consent discussion and included in the consent form and any other written information. Also, the person responsible for conducting the informed consent discussion is required to sign and date the informed consent. The document must specify the parties granted direct access to the patient s original medical records. 

For out-patient prescriptions, it is the responsibility of the pharmacist to perform a clinical check on the prescription. This will follow the same stages that are followed when performing a clinical check on an NHS prescription (see Section 3.3.4). The main key difference is that the hospital pharmacy staff will not have access to the patient s patient medical record (PMR) as this is usually held on the computer of the patient s usual community pharmacy. Therefore, it will not usually be possible to check for interactions with previously prescribed medication. In summary, the following points need to be considered ... 

New York City, Department of Health and Mental Hygiene. Key Agency Impact-2003, http // www.nyc.gov/html/doh/downloads/pdl/public/accomplish 2003.pdf, last accessed 3-12-06 Lazarus, R, Kleinman, KP, Dashevsky, 1, DeMaria, A, Platt, R. Using Automated Medical Records for the Rapid Identification of Illness Syndromes (Syndromic Surveillance) The Example of Lower Respiratory Infection. BMC Public Health, 2001. http //ww w.biomedcentral. com/1471-2458/1/9, last accessed 3-12-06... 

Most analytical devices used in clinical laboratories are directly linked or connected via an electronic interface to a laboratory information system (LIS). In this progression, many different informatic functions (see Chapter 18) are used, including the electronic transfer of data from the analyzers to the LIS and ultimately into a patient s electronic medical record. This provides healthcare professionals with quick, accurate, and appropriate access to the patient s medical history and information. 

Information systems are often described in terms of the entities about which they manage information, the attributes that describe those entities, and the relationships between the entities. This approach to modeling the information is called entity-relationship modeling or E-R modeling. Patients, providers, specimens, and orders are examples of entities, and medical record number, provider identifier, accession number, and order number are all examples of attributes. The relationship between these entities is represented by a data structure that includes a particular patient identifica-... 

The immediate resolution to these issues is to ensure that the complete medical record is secured and that hospital employees and others access only information that is needed for patient care. All employees should be made aware of policies related to confidentiality of patient records and the importance of adhering to principles of patient privacy In... 

GPs are increasingly using computers for accounting, prescribing and medical records, and screen advertising is an alternative to print. However, care must be taken that patients do not have access to the advertisements in countries where DTC advertising is prohibited (Nolan, 2000). 

For pharmacists to participate effectively in collaborative drug therapy management in a timely and cost-efficient manner, several conditions must exist 1) a collaborative practice environment 2) access to patients 3) access to medical records 4) knowledge, skills, and ability 5) documentation of activities and 6) compensation for their activities. 

Access to a patient s medical records is essential to the provision of collaborative drug therapy management. In fact, it is only under these conditions, wherein the phamiacist has adequate knowledge of the patient and the patient s history, disease states, drug therapy, and laboratory and procedure results, that quality care can be rendered. Much work is being done in this area, via computerization of medical records and network facilitation of electronic data, to ensure this key element is in place to facilitate patient care by health care providers. 

It may be mission critical to the profession for pharmacists to gain or maintain read/write privileges where all pharmaceutical care contributions can be viewed by all caregivers. Additionally, pharmacists will need to be able to access diagnosis, laboratory, and other charted information such as demographics on a common medical record. Thus, at a minimum, it will be necessary for all pharmacy software to be able to be integrated into the electronic medical records as they emerge. 

The medical record is another source of medication and health-related information. Access to this record may be limited in certain practice settings however, it can be a valuable tool to review prior to conducting your patient drug history interview. Some practitioners use medical release forms to obtain medical record information such as laboratory data from other institutions required for drug therapy monitoring. 

Therapeutic interchange, as defined herein, may be executed by pharmacists if the authorized prescriber is notified either verbally or in writing within a reasonable time frame, and if the pharmacists have access to medical records and appropriate laboratory or other test results as required by the therapeutic interchange policy. Exceptions to this procedure must be stated clearly in the policy. 

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