Medical Record Documentation - Ethical and Legal Issues

A medical record is a history of someone’s health. Most hospitals and doctor’s offices use electronic health records. Medical records are an essential piece of documentation that follows us throughout our lives. They are both a medical and legal document that comes with certain stipulations and rights that prevent the information from falling into the wrong hands or being unlawfully shared.

What’s in a Medical Record?
A medical record includes information about a person’s:

age, gender, and ethnicity
height and weight
medical problems (such as asthma, epilepsy, or diabetes)
mental health issues (such as anxiety or depression)
medical test results (from lab tests, X-rays, etc.)
medicines, including doses and how often the medicine is taken
allergies to medicines (both prescription and nonprescription), insect stings and bites, food, and any other substances (such as latex)
surgeries and hospitalizations
immunizations (shots)
billing and insurance


Who Can See My Child’s Medical Records?

Usually, doctors can share medical records for kids under 18 years old only if the patient’s parent or legal guardian gives permission. In some situations, though, doctors can share them without that permission (for example, if the child’s health or safety is at risk).


These records are important for future and current health professionals to better understand the patient’s health and wellness, along with any information that might improve care. However, this isn’t the only way medical records can be of service. Here are some of the top uses for medical records outside the healthcare field.

Legal cases can benefit from medical records, depending on the case. One popular example of this is personal injury law, where documentation regarding a client’s health would most certainly be necessary for a legal setting. These records cannot be accessed without a person’s consent. However, retrieving medical documents for legal solutions can be a bit of a hassle. Having the right medical document retrieval service can help expedite the process.

Insurance claims are another area where your medical records may be of service. Insurance companies often request medical documentation when evaluating claims so that any medical bills match claims that are made. In any case, they will need to have a person sign a release form to view and evaluate medical records.