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?

Answer 1

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?

Absolutely Not. The occurrence of an adverse events due to medical negligence can cost patient his life and is a serious offense. As we know, the documents are at legal hold due to adverse event occurred, there is a strong possibility of a legal suit against the physician and the hospital. As per the Moral code of conduct, Medical Ethics and HIPAA law the HIM cannot allow the physician to tamper with a legal evidence that can prove the medical negligence. The medical record if altered can have very serious legal implications and severely affect the reputation and lives of the people n the organization. The HIM can be sued for conspiracy and accessory to the crime and both of the can have their careers terminated. Also, ethically the medical negligence is not tolerable as medical care can literally impact the life of the patient and such actions should be dealt with appropriate actions. Hence HIM director though his fiend in personal capacity cannot interfere or help in official situations to allow the physician access to the record to add the documentation.

2. If the HIM director did give the physician access to the record, what ethical issues does this decision raise?

If the HIM director compromises the document put on legal hold, it can have sever ethical issues and pose the following ethical issues such as

1. Violation of institutional code of conduct

2. Violation of Medical ethics

3. Violation of HIPAA privacy laws

4. Violation of doctor-patient trust in ethical treatment

5. Impact on societal trust on medical professions

Therefore, the access to healthcare records to physician by HIM director can have serious morality issues and can have impact on patient care and trust