CHAPTER 14: MEDICAL RDECORD

I.Patients clinical record

Is the source of all information regarding
confinement and treatment in a hospital
or clinic (present & past medical history)
After discharge, the record is forwarded to
the record section under a competent
safe keeper
If it is necessary, such changes must be
properly signed by the person making
the change
Clinical record is a property of the
hospital
Privacy of patients record is protected by
the privileged communication statute
There is no law as to how long such
record must be preserved
Requisites for admissibility of business
entries are:
1.) entrant must be deceased or outside the
Philippines or unable to satisfy
2.) Entries must have been made at or near
the time of the transaction to w/c they
refer
3.) Entries must have been made at by the
entrant in his professional capacity or in
performance of his duty
4.) Entries must have been in the ordinary
or regular course of business or duty
5.) Entrant must have been in a position to
know the facts therein stated
II. What patients clinical record
includes
1.) Patients medical history
2.) Results of examination
3.) Records of treatment
4.) Copies of laboratory reports
5.) Notations of all instructions given
6.) Copies of all prescriptions and notes on
refill authorization
7.) Documentation of informed consent
when applicable
8.) Any other pertinent data
III. Reasons for patients clinical record
1.) Provide the best medical care
2.) To supply statistical information
3.) Provide legal protection
IV. Correcting a handwritten entry on
patients clinical record
1.) Draw a line through the error

2.) Insert the correction above or

immediately following
3.) In the margin, write correction or
Corr, your initials and the date
V. Right of access to clinical record
1.) Patient
Patients right to access doesnt include
to physically possess the original copy
but only a certified copy of the original
Subpoena duces tecum: through this the
court can order the hospital to bring the
original during the hearing
2.) Attending doctor
right to access doesnt include to
physically possess the original copy but
only a photocopy
3.) Hospital
owner of original copy
medical record of the patient is a part of
the hospital
4.) Nurse
Has the right to access bec. She has
entries in the medical record
Right to photocopy but not original copy
5.) Insurance and HMO representation
Bec. The patient pre-sign an authority
designating the insurance or HMO
representative authorizing the latter to
have access in the patients medical
record
VI. Types of medical records and
confidentiality
2 types of medical record:
Hospital medical record
Physicians private office records
Failure to maintain complete, timely and
accurate records can constitute medical
malpractice
Failure to maintain confidentiality of
medical records, physician and hospital
may subject for malpractice or invasion of
privacy
VII. Documentary evidence
1.) Best evidence rule
Original of a document or writing is the
best evidence of such document; must
be produced unless the original is lost,
destroyed or unobtainable
2.) Secondary evidence
Substitutionary evidence w/c becomes
admissible, when the best evidence or

original document is lost or destroyed,

cannot be produced in court or is in the
custody of the adverse party
3.) Parol evidence rule

Parol or oral evidence of the prior or

contemporaneous agreements is not
admissible to vary, modify or contradict
the written agreement