Doctor Patient relationship with EHR

We all have a family doctor and many of us also turn to professional doctors. Did you know that everyone has the right to review their medical records at any time? Everyone is also entitled to receive a copy of it.

Knowing your right as a patient may be of great value in certain cases. According to the law, every treatment given by a therapist must be recorded in an electronic health record system. The record will include details identifying the therapist and patient, information regarding the medical treatment, medical history as provided by the patient; the current diagnose and further health care instructions.

This law is important in medical, legal and administrative terms, but there are still medical teams who do not insist on an accurate medical record editing and so end up harming themselves, their patients and the whole health care system.

The importance of fully writing the electronic medical record is reflected in almost every situation during patient treatment. For example, patients undergoing a series of tests by different medical teams can not pass on medical information between teams since they are not aware of the need to do so. Missing information may compromise the ability to properly diagnose the patient's condition therefore, have direct outcomes to the doctor's decision on how to treat the patient.

Here is a good example showing the possible tragic consequences of neglecting proper usage of electronic health records. An unconscious patient is hospitalized in a surgical department with acute gastrointestinal infection. The patient was given an infusion containing anesthetic. The therapist who inserted the anesthetic did not mention it on the patient's medical record.

During the doctor's visitation hour, after examining the patient's EMR, the doctor thinks his instruction was never implemented. At that moment, fearing that the patient will wake up, gives an order about giving anesthetic to the patient. The patient who had already received one dose of anesthetic, as noted above was not registered, gets another dose and dies of overdose of anesthetic.

According to the law, it is the doctor's duty to fill electronic health records. Every patient has the right to review or copy the relevant medical record for his needs. The electronic health record held by the medical staff includes the patient's most secret and personal medical details, so it really belongs to the patient.

Allowing the patient to review his or her medical records, supports even more fundamental rights, including the right to receive any information about medical treatments, the right to refuse medical treatment without sufficient information, the right to know who the medical staff is and more.

In special and rare cases where there is a concern for the patient's health, hospitals or clinics can refuse to give the patient to view or copy his or her health records. Every medical facility has a medical records department whose purpose is to gather patient's requests to receive their EHR files and exercise their right to review their medical material.

Every patient has to know that he or she has the right to receive any medical record that was written during his or her medical treatment.

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