PATIENT RECORD AND ITS

RELEVANT LAW
TABLE OF CONTENTS

a) Privacy & Confidentiality of Patient...................................................................1

Introduction...............................................................................................................1

Body..........................................................................................................................1

Conclusion.................................................................................................................2

b) Informed Consent................................................................................................3

Introduction...............................................................................................................3

Body..........................................................................................................................3

Conclusion.................................................................................................................4

c) Specialized Patient Record..................................................................................4

Introduction...............................................................................................................4

Body..........................................................................................................................5

References.................................................................................................................8
a) Privacy & Confidentiality of Patient

Introduction

In contemporary health care systems, confidentiality and anonymity are highly significant,

particularly in the field of family therapy and child care. Nowadays, the effect of privacy and

confidentiality in the health care system needs to be investigated. In essence, the issue of privacy

and confidentiality does not only raise ethical but also legal concerns as practitioners in the

healthcare industry are obligated to uphold confidentiality and protect patients' data from

violations (Milholland, 1994). But healthcare practitioners may face a challenge between

protecting children's confidentiality and privacy and families' understandable need to get data

about their children's diagnosis and status.

Body

Healthcare professionals should guarantee that they have sensitive knowledge about patients.

Trafficking through the use of illegal drugs is some criminal activity that a physician may

participate in. Upon the realization of such drug use, the health worker is faced with the dilemma

of whether or not to report such cases to relevant authorities. If they do so, they will be infringing

on the patient’s right to privacy and confidentiality (Olsen, 2008).

Health record security is the privacy and confidentiality of data, which a patient records at the

request of a medical officer and the reception of health care. Information on the patient's request,

condition, and other records on his health and privacy, which have been obtained from

examinations and procedures, prophylactic and recovery is medical confidentiality not subject to

the release.
When a patient applies for medical assistance and accepts it they have the right to keep the

information confidential about the fact that the request for medical assistance has been made, on

their history, the diagnosis and other information, and to observe and handle them, as well as the

option of people to whom data about the patient's health status may be provided on behalf (Terry,

2007). Throughout the case of a breach of a patient's rule, a lawsuit can be filed immediately

with the director of the health and prevention establishment, the related medical professional

organizations, certified boards, or the Judge.

The citizen's right to the privacy of the information they transmit on request and delivery of

medical treatment, along with other information that renders medical private, creates medical

employees' and everyone else's responsibility for transparency.

Conclusion

Where there are no set rules on whether to report or not to report criminal activities, the

physician should be guided by both the ethical principles as well as what he feels is morally right

and has a greater benefit. In case a criminal activity is carried out by a patient and a third party

wishes to report it, then the health care provider should not report should instead maintain

confidentiality (Demirsoy, 2016).

The physician may also arrange for the patient to receive help such as counseling to prevent the

criminal activities from continuing without necessarily infringing on the patient’s privacy. This

should however be done after the patient has given informed consent and is comfortable with the

idea. This is all the concept of confidentiality and privacy of the patients.
b) Informed Consent

Introduction

Informed consent is the method by which a fully informed patient can participate in a research

project after being informed of its procedures, risks, and benefits. Informed consent is a part of

the ethical and legal rights that research participants or patients have. It remains a critical

procedure for any research project. Research subjects or patients must understand all issues about

the research or procedure before giving their full and conscious consent to the researcher or

physician to proceed with the procedure (Berg, 2001). It is necessary to understand the history of

informed consent in research to appreciate its importance.

Body

Informed ensures that all relevant knowledge is made clear to the consenting person. Not to

consider it everything just to say that a specialist has clarified the consequences to you (for

example, a lawyer for legal issues or a doctor for a surgery). It does not indicate that the

individual is conscious of what the smart move is, but it does not mean, that the dosage doesn't

mean that they are necessarily going to make a good choice. It just means that you have ample

knowledge to make a reasonable decision for an ordinary citizen (Cordasco, 2013).

Informed consent aims to ensure that research subjects understand the process, benefits, and risks

associated with the study. However, the process has serious challenges in its application.

Researchers have failed to obtain fully informed consent from their subjects. The requirement to

obtain informed consent is critical for protecting marginalized groups from taking part in

procedures they do not understand.

Informed consent has remained significant in research. It has originated from several laws and

declarations like the Nuremberg Code, the Belmont Report, and the Declaration of Helsinki

(Hallock, 2017). These documents strive to ensure that researchers and doctors behave ethically

throughout their procedures.

Conclusion

The theory of informed consent to therapy is that a patient must give consent before some kind

of medical therapy, examination, or evaluation is obtained. To be true the consent shall be

compulsory, informed, and the person making the consent shall be determined to accept the

decision. Consent can be offered expressed or implied, depending on the care suggested. The

process is prone to a misunderstanding between the subject and the researcher.

Misunderstandings in obtaining informed consent may result from both the researcher and the

subject. Such barriers contribute to unethical practices or negative outcomes in research

procedures. It is the responsibility of the researcher to inform research subjects about the

purpose, benefits, and risks of any procedure before such subjects take part in a procedure.

c) Specialized Patient Record

Introduction

The CPR or Electronic Health Record (EHR) is characterized as an extensive archive,

accessible and maintained via the Health Care Net, of personal health-related records.

The sharing of medical photographs and medical documents in the form of specialized

patient reports involves distant diagnostic facilities. Most healthcare practitioners rely on

specialized medical records. It can be available in stationary hospitals, but also emergency

rooms, nursing homes, ongoing service centers, medical services, laboratories, research
facilities, rehabilitation centers. As and where possible, an optimal computerized medical

record should be available. To avoid improper use or modification, data databases with

confidential information must be monitored (Klar, 2004).

The creation of algorithms to build risk assessments for a wide spectrum of medical and dental

disorders is a natural extension as electronic health reports grow more allergic. The method of

choosing suitable care alternatives and creating a context that can be used by dentists and

patients to make comparisons treatment decisions and findings can be created by computer-based

artificial intelligence.

Body

As electronic patient records are more widely used, staff are increasingly using computers in

their management of patients. Computer keyboards are not easily cleanable, particularly between

keys; as a result, they can become heavily contaminated. Insufficient or unusual purification

permits the existence and persistence of microbial toxins on ambient surfaces and may be

utilized by device keypads (and mice) to provide patients with no direct risk. Nurses recording

patient observations and medical staff passing from keyboard to keyboard usually without hand

hygiene may transmit pathogens to other patients via contaminated computer keyboards.

With time and attention, the device should have a full, flawless perspective of the patient.

Configurable viewpoints can be used to meet the knowledge and workflow needs of a particular

user. The clinical engineer will obtain the requisite knowledge to streamline the pragmatic

decision-making from a comprehensive and summarising view that incorporates the relevant

details. Displays should be set to prioritize essential statistics, thus eliminating clutter but quick

access to all related data. The computerized data of patients with supportive features, such as
expert networks, treatment pathways, guidelines, legislation, reference documentation, and

medical literature, should have complex relations.

To address the medico-legal effects of voicing a condition explicitly on the web, as a patient was

not tested by the consultant, an organization provides service from the general practitioner of the

patient. Since no patient sends data directly to the counselor, no connection is formed between

the doctor and the patient. The patient is provided for by their referring physician who prefers to

approve or deny his view.

Though hackers can enter electronic networks, the stealing of medical identities has now become

more significant. Much like anyone who might park outside a pharmacy and hit the credit card

clearance process remotely, they may try to block interactions between clinics or even between

units of hospitals. Kieke reports a study that three percent of identity fraud crimes by the Federal

Trade Commission. This is research by the Federal Trade Commission. Theft can be used to

access medical care illegitimately, make false statements, or try to procure medicines (Kieke,

2009, pp51-52). When the identification has been destroyed, it can be purchased and resold

numerous times to refute the allegations and to regain its reputation.

The time of responses would have to be speedy enough and workstations readily available to the

care point should be comfortable. A benefit is telephone connections. Accessing patient data via

wireless communications through mobile devices is an appealing option for patients, but

accessibility and protection challenges must be overcome before they are completely enforced. A

significant range of fields of study, education, decision support, and outside communication is

now funded by the patient database. Via management, funding, quality control, and study fields,

aggregate data is also available.

Conclusion

An electronic record that enables exchanges between medical provider and readabilities, and

does not depend on the old paper method that needs to be delivered manually or at most faxed

among offices is referred to as the patient's specialized record. Developing appropriate EHR

frameworks will add a new level to patient analyses of the health records. Adequate ties for

describing scientific names, facts, various views, and other helpful strategies will vastly improve

the assistance offered to the patient, based on the users' profiles that help enhance the utility and

proliferation of the patients' health records (Bocionek, 2003).

Finally, a lack of applicable regulatory precedents is the root cause of the confusion surrounding

the responsibility for e-medicine. Technology and experience of e-medicine are still emerging

and the future risks for insurance providers are still uncertain. IT offers various rewards but does

not go infinite and unlimited. Doctors need to know about these innovations to establish

reasonable standards, optimize their profit, ensure the safety of patients and prevent catastrophic

dangers. The safeguards and confidentiality of secure personal health records should be ensured

by organizations. They need to consider and protect the protection and safety of patient records

under the laws of privacy. In years, several efforts have been made to advance clinical

technology, to reform medical records, and to foster more diligent health care practitioners. The

full spectrum of software is not required in specialized hospitals and many doctor's offices, even

with subsets or main modules enough. Although it should be important for any EMR

implementation to be able to arrange and view medical data meaningfully in line with any

standardization and the potential to move information to other locations as necessary. In addition

to the requisite technologies, the human needs of using the device must be looked at. For the
resounding success of any implantation, users, doctors, and nurses, in particular, are critical. The

entire architecture can be moot by not fixing problems that result from this group of users.

References

Demirsoy, N., & Kirimlioglu, N. (2016). Protection of privacy and confidentiality as a patient
right: physicians' and nurses' viewpoints.

Milholland, D. K. (1994). Privacy and confidentiality of patient information. Challenges for

nursing. The Journal of nursing administration, 24(2), 19-24.

Olsen, J. C., Cutcliffe, B., & O'Brien, B. C. (2008). Emergency department design and patient
perceptions of privacy and confidentiality. The Journal of emergency medicine, 35(3), 317-320.

Terry, N. P., & Francis, L. P. (2007). Ensuring the privacy and confidentiality of electronic
health records. U. Ill. L. Rev., 681.

Berg, J. W., Appelbaum, P. S., Lidz, C. W., & Parker, L. S. (2001). Informed consent: legal
theory and clinical practice. Oxford University Press.

Cordasco, K. M. (2013). Obtaining informed consent from patients: brief update review. Making
health care safer II: An updated critical analysis of the evidence for patient safety practices,
2013, 461-470.

Hallock, J. L., Rios, R., & Handa, V. L. (2017). Patient satisfaction and informed consent for
surgery. American journal of obstetrics and gynecology, 217(2), 181-e1.

Klar, R. (2004). Selected impressions on the beginning of the electronic medical record and
patient information. Methods of Information in Medicine, 43(05), 537-542.

Belongia, E. A., Kieke, B. A., Donahue, J. G., Greenlee, R. T., Balish, A., Foust, A., ... & Shay,
D. K. (2009). Effectiveness of inactivated influenza vaccines varied substantially with antigenic
match from the 2004–2005 season to the 2006–2007 season. The Journal of infectious diseases,
199(2), 159-167.

Bocionek, S., Hanslik, M., & Russwurm, S. (2003). U.S. Patent No. 6,551,243. Washington, DC:
U.S. Patent and Trademark Office.