The management of health records and health information systems is a societal effort to protect patients rights
The
human rights issues started in the twentieth century getting momentum with the
Universal Declaration of Human Rights.
It is this declaration where patient rights are anchored. In this paper, the author is going to discuss
the views that management of health records and health information systems is a
societal effort to protect patients’ rights.
Definition of Terms
According
to Wikipedia, “The terms medical record, health record, and medical chart are
used somewhat interchangeably to describe the systematic documentation of a
single patient’s medical history and care across time within one particular’s
jurisdiction”. The Free Dictionary
defines medical record as “A
chronological written account of a patient’s examination and treatment that
includes the patient’s medical history and complaints, the physicians’ physical
findings, the results of diagnostic tests and procedures, and medications and
therapeutic procedures”. On the
other hand the term patient rights is defined by the American hospital
Association as, “Patient rights
encompass legal and ethical issues in the provider-patient relationship,
including a person’s right to privacy, the right to quality medical care
without prejudice, the right to make informed decisions about care and
treatment options, and the right to refuse treatment.” The consumer council of Zimbabwe defines
patient rights “as social and individual
rights. Social rights cover aspects such
as the quality and accessibility of health care, while individual rights relate
to basic human and consumer rights.”
The
Patients Charter as promulgated by the consumer council of Zimbabwe (2006) says
patients had what are called “General Rights to Access and Treatment.” Included in the above rights is the issue of
confidentiality. The confidentiality right
says, save for the requirements of the law, all information concerning a
patients illness or personal circumstances will be kept in confidence and used
only for the purposes of their treatment.
The American Bill of Rights (2010) also says, “You have the right (patient) to talk privately with health care
provides and have your health care information protected.” The management of health records is indeed an
effort by the society to safeguard patient rights. It is the encouragement of all records
management practitioners that access restrictions to patient is restricted.
Chwanza
K & Tsvuura G (2011:101) says in an effort to protect the right to
confidentiality “clear guidelines should
be in place as to which members of hospital staff are entitled to have access
to patient case notes and other potentially sensitive records”. Chiwanza and Tsvuura go on to say senior
staff of the hospital should be identified who can authorize the supply of case
notes outside the hospital. Some countries
had laws which regulate the release of health records to patients-themselves
and relatives. All the above records
management principles are-there to protect the rights of the patient.
The
consumer council of Zimbabwe Patients Charter (2006) says the Patient had a
right to consent. “In the event that surgery is anticipated in your treatment plan, you
have the right to be consulted and to be informed about the nature of the
operation. Where risks are known, you
will be informed”. Tsvuura and
Chiwanza concur with the Consumer Council of Zimbabwe Patient Charter when they
said ‘the patient’s consent should be
obtained before confidential details are released”. Patient case notes had a dual copyright, that
of the medical practitioner attending the patient and the patient. The consent of the patient is needed before
the case note is used for research or any other purposes in an effort to
protect the rights of patient.
The
American Hospital Association says patients had right of complaints and appeals. Patients had right to fair, just, and
objective review of any complaint you have against your health plan, doctors,
hospitals, or other health care personnel.
This includes complaints about waiting times, operating hours, and the
actions of health care personnel and the adequacy of health care
facilities. With the above in view,
health records management encourage the management following laid down records
management principles such as the life-cycle concepts. The lifecycle records management illustrates
the record lifecycle from creation through final disposition. The cycle applies to all types of records
including health records.
The
life-cycle concepts ensure that records are not disposed too early to avoid
unnecessary litigation by patients if they fail to get their health records
from health institutions. It ensures
that records are disposed when they are due for disposal for early access to
current records in the registry. If records
are kept unnecessarily for to long in the registries, the retrieval period of
the needed records becomes to long due to clogging of storage equipments.
The
use of computers (electronic records management) can enhance the fast
accessibility of patient records shortening the number of patient’s grievances
because information will be readily available.
A comprehensive electronic records management programme ensure a proper
document assembly document version (or revision) control, document check in and
check out services and document security consists of all the technical document
tools to protect, control, and monitor document access, (FORE Library) www.ahima.org
The
Consumer Council of Zimbabwe Patients Charter 2006 says one of the Patients
Right is that of choice. It says a
patient must exercise their right to choose health workers who provide them
with treatment or advice, the place and type of treatment that is
provided. After being informed of the
possible options, patients have the right to refuse or halt any medical
interventions. Patients are allowed to
seek a second opinion at any given time while consulting the same medical or
health care delivery system. The use of patient
based case notes can assist patients to go and look for alternative medical
practitioners of their choice.
CONCLUSION
The
author agrees with the notion that management of health records and health information
systems is a societal effort to protect patients’ rights. The records management principles such as the
life-cycle concepts, continuum concepts, provenance and respect-des -fonds and
others are there to protect, the accessibility, choice, privacy,
confidentiality and other patients patient rights.
BIBLIOGRAPHY
The
Consumer Council of Zimbabwe, 2006, Patient Charter, found on http://www.ccz/zw/articles/details.php?article
id=1
http://library.ahima.irg/xpedio/groups/public/documents/ahima/bok1_040405.hcp?dDocName=bok1_040405
management for healthcare
Chiwanza
K & Tsvuura G, 2011, management of hospital records and health information
systems, ZOU, Harare, Zimbabwe.
Etiwel Mutero works for the National University of Science and Technology,he holds a National Certificate in Records and Information Science from Kwekwe Polytechnic and a Bachelor of Science Honours Degree in Records and Archives Management from the Zimbabwe Open University.Do you want assistance in writing your college or university assignment? You can contact Etiwel Mutero on 0773614293 or etiwelm02@gmail.com
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