Health Care Ethics – Confidentiality of Medical Records Policy
It is crucial to understand that ethical values are essential for any given provider of health. It is derived from ethos, a Greek word that essentially means Character. Moral values are rules of conduct that are universal and offer a practical basis for identifying the kinds of intentions, actions, and motives that are valued. Ethics is simply a guiding beacon ray that governs how a medical practitioner or a group of medical practitioners will behave or conduct themselves in the medical profession. In this case, the point of interest will relate to the wrong and right actions and generally encompass the process of decision-making of determining the final consequence of those actions. Every individual has a grouping of personal ethics and morals. With this in mind, ethics is vital because workers and other healthcare providers can realize the dilemma that is often present in medical practice. It helps in making good judgments and even decisions based on their values whilst keeping within the bounds of the laws that govern them. With this in mind, for nurses to practice with integrity and competency in the healthcare profession, there have to be regulations and guidance, such as the Code of Ethics developed by the American Nurses Association (ANA). Therefore, with this knowledge in mind, it suffices to maintain that this paper will explore the notion of medical records and the importance of confidentiality and describe one legal standard, regulation, or policy related to privacy. Also, it will touch on medical records in healthcare and provide explanations for how such policies and procedures should be communicated to the employees.
Foremost, it is imperative to understand that when the notion of medical records comes to mind, they relate to documents that provide all details about the history of the patient, diagnostic test results, clinical findings, medication, patient’s progress, and pre and postoperative care. When they are written correctly, the notes will offer support to the doctor concerning the correctness of the treatment. Medical records are one of the most vital aspects on which virtually every medico-legal battle is either won or lost. Also, an effective medical record serves the medical practitioner’s interest and the patients under their care. It is vital that the doctor in charge of the treatment efficiently document the management of patients under their care. Throughout history, medical record keeping has gradually evolved to become a science. The answer to the dispensability of the majority of the medical claims of negligence rests squarely on the quality of medical records’ quality (Bali, 2011). The maintenance of records is virtually the only way for the medical practitioner to prove that the treatment provided under their care was done properly within the policies of the medical profession. In many instances, it is crucial to understand these medical records are the only proof and source of truth, often being more reliable than just relying on memory.
Also, there are numerous problems that hospitals face when it comes to efficient records maintenance. These problems include failure to constantly review the outdated form, failure to make use of trained personnel in the maintenance sector, and inappropriate storage of inactive records. As such, medical personnel involved in the management of a patient must properly maintain the records of the patients for the proper evaluation of their patients, to make plans for the protocols of treatment, and to ensure that the legal system has access to the proof of treatment through documentation of the patient’s records, which implies that medical records must be written properly, with the intention of preserving to serve the doctor’s interest and that of their patient.
Furthermore, patient confidentiality is vital for the building of trust between medical professionals and patients. In this case, patients will have to inevitably disclose their health information, especially if they trust their doctors and healthcare providers. In this case, relationships that are trust-based and physician-patient often lead to better interactions as well as higher-quality health visits. By saying that health care professionals who take privacy obligations seriously and take time to explain the rules of confidentiality inevitably have patients who provide honest symptoms to them, this results in accurate treatment (“Patient Confidentiality in Healthcare | Maryville Online”, 2021). Also, it helps medical practitioners make decisions that are better-informed, accurate diagnoses, and personalized plans of treatment that often lead to better outcomes of health.
Besides, confidentiality is an integral right of persons who receive support and care. It is a part of the interrelationship of the trust that patients have for their healthcare support workers. In this case, the patient’s information has to be shared on a need-to-know basis. The practitioners involved in caring for an individual do not share the information with another person, regardless of their relationship with the patient, without their permission. In this case, a patient may be unwilling to let their family know their health status or if they have been suffering from the ailment. It increases the essence of protecting information that is private from viewing or hearing that is accidental. As such, it is imperative to understand that when health care providers discuss health of patients under their care, they have to take precautions, lest their discussion is heard by persons that this information does not involve them. Various legislations have been mandated to ensure that the confidentiality of documents and relevant information of the patients have been protected. For instance, the General Data Protection Regulation (GDPR) 2016 is a regulation that was passed to regulate the usage of the patient’s information to balance the person’s right to confidentiality, as well the need of the organization to use for their own purposes such as research (The Care Certificate Workbook Standard 14, 2021).
With this knowledge in mind, there emerges the question of how to efficiently relay such policies and regulations to employees in the health care organization. In this case, the management must be transparent to the medical employees. Staff meetings can be held to communicate policy updates. Another way to achieve transparency is that the new policy should be posted in common areas such as the notice boards or the break rooms, where these policies will be accessed readily. Hard copies can also be handed out to the employees in the form of memos or handbooks that have been updated, and the employees can be informed of the changes either through emails, password-protected sections of the company websites, or the intranet.
Furthermore, such policies need employees to comprehend their essence fully so that they can provide training whenever necessary. In this case, if the policies are complex, there is a need for training to be scheduled based on an ongoing or as-needed basis. When these measures are taken, the management can hold meetings and sessions that incorporate the employees’ opinions, often allowing for anonymity for all employees to feel comfortable voicing their opinions without actually holding themselves back (Team, 2021). Also, two-way communication is vital in ensuring that the employees do not simply voice their concerns but also that the management is addressing these measures honestly and openly.
In conclusion, for nurses to practice with integrity and competency, there have to be regulations and guidance in the healthcare profession. This includes the Code of Ethics, rules on the use of patient information, proper and professional work ethics, adequate keeping of medical records, and the importance of confidentiality.
References
Bali, A., Bali, D., Iyer, N., & Iyer, M. (2011). Management of medical records: facts and figures for surgeons. Journal of maxillofacial and oral surgery, 10(3), 199.
Patient Confidentiality in Healthcare | Maryville Online. Maryville Online. (2021). https://online.maryville.edu/blog/patient-confidentiality/.
Team, P. (2021). How to Effectively Communicate Workplace Policy Changes. Peninsulacanada.com. https://bit.ly/3FsEltt
The Care Certificate Workbook Standard 14. (2021). [Ebook] (p. 1). https://bit.ly/3oC1KlY
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Question 
You are the new office coordinator of a small multi-specialty group practice. You have been tasked with updating the office policies on medical records and confidentiality and training the employees on this important topic.
Confidentiality of Medical Records Policy
For this assignment, you will address each of the prompts in 3-5 pages, not including the title page and reference page. You are expected to use a minimum of two references and utilize APA style:
Discuss medical records and the importance of confidentiality.
Describe one legal standard, regulation, or policy that is related to confidentiality and/or medical records in healthcare.
Explain how such policies and procedures should be communicated to employees.