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Legal Aspects of Health Records Management

The document discusses the legal aspects of health records in countries without clear laws on the topic, like Nigeria. It notes that health record policies are set by individual hospital management boards instead of national laws. It identifies 7 key legal aspects of health records, including the need to create and maintain them for each patient, ownership of records, patient access, confidentiality, consent requirements, and use in courts. Maintaining accurate health records serves important legal and non-legal purposes like documenting patient care, defending doctors and hospitals, and supporting billing and research.

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92 views1 page

Legal Aspects of Health Records Management

The document discusses the legal aspects of health records in countries without clear laws on the topic, like Nigeria. It notes that health record policies are set by individual hospital management boards instead of national laws. It identifies 7 key legal aspects of health records, including the need to create and maintain them for each patient, ownership of records, patient access, confidentiality, consent requirements, and use in courts. Maintaining accurate health records serves important legal and non-legal purposes like documenting patient care, defending doctors and hospitals, and supporting billing and research.

Uploaded by

Tundex Concept
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd

The legal aspect of health records should be best discusses in countries that have laws

relating to the practice of health records.


However, in countries like Nigeria, there is / are no law(s) guiding the practice of the
profession. We rely on We rely borrowed and common laws, i.e. policies relating to the practice
of, health records profession. These policies are made by each Hospital Management Board.
Early, in the process of establishing Health Records Policies, it is important to review
the laws and regulations as relating to Health Records which govern the institutions for
which the health records system is being developed. Are view of the code of ethics of the
National Medical Society and of other professional groups is also helpful
The legal aspects of health records are grouped under the following heading:

1. The need to create and maintain Health Record on each patient treated in the Hospital.
2. Ownership of Health Records
3. Patient's Right of Access to the Records the Patient's Right of access in the hospital
4. Confidentiality of Health records
5. The Consent/Authorization
6. Uses of Health Records in the Court of Law
7. Preservation/Retention of Health Records

THE NEED TO CREATE AND MAINTAIN HEALTH RECORDS ON EACH PATIENT


TREATED IN THE HOSPITAL
The creation and maintenance of Health Records on each and every patient treated in an
Hospital serves as an evidence of what the patient problem is and the treatment rendered and
received. In other words, it serves as documentary evidence on the patient and how he or she
was attended to in the hospital. The need to create and maintain Health Records on every
patient treated in the hospital can be considered from both legal and non - legal point of view.

1.1 UNDER LEGAL POINTS OF VIEW

a. It serves as a source of defense for doctors and the hospital in case of litigation that may
be brought against either of the doctors or the hospital
b. It serves as documentary evidence for patient
i. In case of claims
ii. In case of settlement of bills
iii. For compensation to the patient and other settlements

1.2. UNDER NON - LEGAL POINTS OF VIEWN

i. The primary purpose is for effective care of patient now and in the future
ii. For statistical purposes
iii. For evaluation of patients care
iv. For research and planning
v. For education and administration purposes etc.

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