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.
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.
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 firstname.lastname@example.org