Medical Records is a ‘legal document’ in accordance with medical ethics. Medical records contain information and future health care. As a written collection of information about a patient’s health and treatment, they are used essentially for the present and continuing care of the patient. In addition, medical records are used in the management and planning of health care facilities and services.
Medical Records is the claims involving patients, lawyers, doctors, insurance companies, government agencies. Information gathered about patients is communication between the two parties, namely doctors and patients.
This includes both the public and private sectors in the information obtained by patients treated by doctors and hospital’s patient record is considered a privilege. Patient’s record is used to ensure continuity of care given to a patient.
Collect and provide data on patients for the purpose of planning and development services, enable connection with the communication between the service provider of clinical through information sharing and other health professionals who contribute to the treatment of patients and used for the research, teaching, learning and provide a permanent record of the activities and events during patient care for medico-legal purposes (in compliance with the legal requirements and the interests of the patient).
Activities involving all the planned or unplanned process aims directly or indirectly to treat the diseases or build a patient’s health. This is done by doctors, nurses, pharmacists and nurses to other lab tests or imaging and so on.
For the ‘incident’, all the events that are expected or unexpected happens on patients usually witnessed by doctors, nurses, pharmacists and other medical practitioners.
Chronology Sequence of activities and events can help clarify the causes and effects, the date, time and complete information, reporter need to be recorded, it is necessary in the event of medico-legal cases. Medical Record as a logbook and documentary evidence crucial to the legal aspects of medicine.
Today, a specific legal body in charge of medical records is not yet available. But all hospitals in the Ministry of Health have guidelines and Circular Medical Records Management as a reference and guide. Medical legal aspects of medical records are many and vary.
In some situations it has the potential to provide a much broader implications for patients, institutions, organizations, companies and employees of medical records that keep medical records for doctors and health professionals and other non-professional staff who handle patient information that relates.
An example is to produce and present the patients the discharge summary and a letter to the doctor who referred to another hospital, for medical where the patient needs to be moved or referred.
Every hospital and institutions have their own policies and the Medical Council is responsible for the hospital standards in determining the guidelines. There are also cases where the issue of negligence communications of medical information.
Liability Under Negligence
Under the law the tort of negligence, the following cases is expected to provide useful guidance to doctors and paramedics, especially when treating patients,
“The duty of doctors to patients … should do it with a level of skill and cautious or alert with a reasonable reason”.
The reason “Volkmann’s”, off her feet due to lack of blood flow. Leg amputated. Results: Doctors negligent. Doctors and paramedics must follow the procedures set out in the treatment of patients in order to avoid negligence. Doctors also need to be willing to be witnesses in court and agreed to attend and give evidence as possible.
However, the appreciation is also given by society to the Ministry of Health who give good service, especially to avoid medico legal cases and complaints received by the ministry.
The improvements that have been made in the ministry itself to provide quality services and acts as an advisor and expert in handling and investigate technical cases of medico legal and coordinating and controlling the medico legal cases including civil suits clinical negligence on the governmental health premises.
Permit to bury, approval form and certification of death by a doctor, autopsy to prepare a report and submitted to the legal authorities. In the Register of deaths / autopsy contain details such as the Personal information of the deceased, cause of death, date and time of death and number of death certificate as well as for the case of medico legal information of the heirs or persons who claiming the bodies and the relationship with the deceased should be clear to prevent misconduct on the body.
The body which death caused by an accident are often in a pitiful physical condition so that there is no direct resemblance to the human form. Knowing the difficulties faced by the families of victims who claim the body, HKL forensic take proactive measures to complete the corpse.
So far, all the staff does not face major problems with the body but often with the problems involving the heirs of the deceased. Talked about the types of corpse in the HKL forensic department, they received the bodies consist of bodies of medico legal and normal bodies.
HKL does not use preservatives on the body, but corpse only kept in the fridge. The bodies of medico legal separated into two categories involving crimes such as murder and not a crime such as accidents, fires and others.
HKL also handling the bodies of patients who died in hospital after an hour of the time of death, the body will be brought by PPK to the morgue. The heirs will be contacted and the bodies will be claimed after the identification process is carried out.
Medico Legal Bodies
The body who was not claimed or with no heirs are not alone, but some are not known their identity caused their burials take place in open field like in the cemetery at Jalan Karak.
The same applies to non-muslim bodies. After unsuccessful efforts to trace relatives, the bodies will be handed over to the Kuala Lumpur City Hall (DBKL) before being burned in a kiln in Cheras.
for the medico legal cases, the majority of the bodies were involving police affairs and the court to undergo a post mortem. Rational, autopsy is conducted to find the cause of the death either it is involving crime or not, but it is only will be carry out if the directive letter by police is given out.
“HKL Forensic Department will conduct an autopsy in accordance with the court calendar for crimes such as murder.
“Due to the death of the individual involves legislation, then his body need to be keep until the letter of approval are given to dispose the body. HKL keeps the body involving medico legal cases for six months the bodies removed, “The freezer temperature to store the bodies is between 2 degrees C to 8 degrees Celsius without using preservatives.
Preserving corpses in the hospital to maintain the physical details of the body is forbidden and they were not able to block the decomposition of the corpse if it is stored for too long.
Officers of the mortuary department was not only faced the challenges in autopsy and funeral, but also by the reaction of the heirs of the deceased. Faced with the family of the deceased, is the most difficult situation since the cases of medico legal death is sudden and the condition of the body is not perfect.
“Not all the autopsies can complete the physical body because there are bodies that cannot be saved. The heirs who saw the body in the heartbreaking situation that are difficult to accept the reality and causes them crying/moaning and the hospital staff had to calm the situation. Accordingly, the hospital set up a special room called the Crying Room for families of victims to calm down so that they are able to continue to claim the body,”
In the Case of Death, Personal Lawyer (deputy) the heir is entitled to review the medical records for carrying out their duties.
Steps in Managing the Potentially Medico Legal Cases
1. “Ownership of Medical Records”
Any cases that involve or potentially a medico legal cases Patient Records shall be kept in a safe place and locked. Patient statistics and reports on infectious diseases, births, deaths, infant deaths, necropsy, child abuse, drug abuse and others need to be recorded the complete information.
Medical Records cannot be given to any party without the authorization of the director of the hospital. If involving the Legislation Case in the Court of Medical Record should be kept until the case completed or closed.
The court with subpoena can ask the summary of medical record made in front of the court. The record may or may not be used as evidence depends on the order of the Court.
If the records will be used as evidence, hospital representatives must get the court order first so that the photocopy is required and the original record is released but returned after the copy is made to avoid missing records, tearing and so on.
Hospitals cannot disobey the order of subpoena which directing to release the medical record. If disobeys it will be deemed not respecting the court “Contempt of Court“. If there are reasons to not allow the records released and failed to provide evidence of “reasonable reasons” should be explained in front of the Court during the hearing of the subpoena. The decision of the Court as a doctrine of privileged communications involving patients, physicians and (Privileged Communication) hospital is too complex to be discussed.
2. Medical Report
Letter of Authorization for Medical Reports Application by a third party, must comply with the following conditions, which is:
- The ORIGINAL Letter of consent signed by the patient or heir. A copy of the marriage certificate / birth certificate of the applicant showing the relationship of the patient.
- If the patient dies, the rightful heir confirmation which is valid according to the law should include the relevant documents as proof
- Medical Report Application for foreign patients who cannot be traced / dead, or his heirs could not be contacted, should be accompanied by a letter of consent from the embassy of the State concerned
For patients under 18 years of age or patients who are unconscious or mentally disabled and deceased, letter of consent from the heir is required.
In the case of medico legal or Legislation, Records of the application of Medical Report will be stored in the Department until the record inactive for 10 years.
3. Rights of Patients Toward Health Information
With user awareness in the field of health care, increased interest became apparent in the field of patients’ rights. The patient information cannot be disclosed easily to unauthorized parties.
It has been suggested that physically ownership records of hospitals and patients have a legitimate need for the information contained therein. If the hospital allows patients to access such information, it shall be in accordance with procedures and policies in writing that outlines the rights of patients to classified information to the extent that it can access the information to share with patients. Earnings of the patient’s information should be restricted after discharge when the doctor was perfectly complementing the documentation of the patient.
Treatment’s information and other investigations carried out on a patient in the hospital only released a report as a copy of the Medical Report, and not the actual patient Record.
The application process for report is like in the Medical Report Guidelines for Hospitals of Ministry of Health and Medical Institutions. X-ray film can be given to patients who should be referred to other hospitals including private hospitals to avoid a repetitive check-up.
4. Releasing Health Information To The Authorized
Most of the applications / requests from third-party payer plan, especially insurance companies, lawyers, police and patients, their relatives, medical staff, public agencies and private agencies who are involved in the treatment of patients will need for patient information.
By practicing good public relations with the applicant, the hospital can provide a quality services. Patient’s information is confidential about the type of disease the patient it does not need to be known publicly.
This privilege is created and justified in terms of the law and ethics as the people think patients should feel safe in giving information to doctors to allow treating them perfectly. Provision of information over the telephone by any party for any purpose is not allowed.
- To Those Who Are Under Age And Declared as Disabled Person in the Terms of Law
In the case of patients who are underage or unsound in the term of law it may be signed by the mother / father, guardian or lawyer for the patient’s behalf. When a patient dies, the administrator of the property, a will signed by showing a valid proof in front of the Department / Medical Records Unit in the form of court documents, a permission letter from the lawyer, the heirs / holder of the property or others who authorized
- Goverment Agency
Government Departments and Public Sector often seek information about their patients’ medical reports. Half of the application is made privately by their representatives or by post. it is better if patient’s approval is obtained first to let the patient know what he signed.
The Exemption Letter of Consent: The Application from the agencies that have been authorized under the provisions of the law for investigation purposes such as:
- “Any agency that has been authorized under the law to gain a medical report of a patient.”
Lawyers who applied to release the information about patients must include in the written consent of the patient or either represented by the lawyer or the opponents. If the patient’s written consent is not obtained, a court action such as issuing a subpoena can be used instead.
Lawyers for medical institutions that against the court civil to be taken on the institute is entitled to have the patient’s information immediately. Therefore, in our understanding, hospitals have the ownership of the patient’s information and can prevent from information leaking out of the hospital except for cases of subpoena, the importance of patient information secured by the court and the lawyers who representing the patients can get the right for the patient’s information that was ordered by court on condition that the objective is good.
As a conclusion, hopefully with a little knowledge of this article can provide information to educate the public, employers, public agencies and others on medico legal cases that have to be manage by the Health Authorities.
The importance of patient’s information and rights, and doctor’s relationship between the patient on how to get information about the patient’s disease in accordance with the rules of the hospital to prevent and reduce the misuse of information or negligence of the staff so that potential cases of medico legal are well maintained.
- Medical Records Manual: A guide for Developing Countries WHO by Professior Dr. Phyllis J. Watson,Head of School of Health Information Management, University of Sydney.
- Medico- legal aspect of Medical Record Administration by Mrs. Kerin Robinson Head of School Medical record administration, Calton, Victoria
- Petikan Berita Harian: Cabaran menguruskan Mayat kes Medico legal: HKL
|Last Reviewed||:||11 August 2017|
|Writer||:||Pn. Rosseriyani Bt. don|
|Translator||:||Pn. Hasnah Binti Ismail|
|Accreditor||:||Pn. Oni Saifura Binti Osman|