Medical Records

A medical record generally represents information concerning a patient that is written following a patient’s visit to health care facilities. The record contains the medical history of a patient as well as all the treatment procedures and methods that are carried out while in hospital.

It is a significant document because it assists in making medical decisions as well as sharing the responsibility with the patient. Bearing in mind that it is a legal document, it can be used to protect both the patient and the doctor while in court. In addition, it has got a legal obligation since it can be used to file a case.

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The document can be written in different forms and most importantly, there are different systems used in the same which are inclusive of PIE charting, traditional narrative, charting by exception as well as source oriented and problem oriented (Iyer, Levin, & Shea, 2006). With that background in mind, this paper shall discuss the legal advantages and disadvantages of PIE charting and problem oriented systems.

Problem oriented is a system that uses a format known as SOAP. The word SOAP represents the subjective data, objective data, assessment as well as the health care plan (Iyer, Levin, & Shea, 2006). The usage of the method started in 1960s and it was an improvement of the narrative method which was being used initially.

Bearing in mind that the method enables medical care professionals to create a problem list indicating all the problems of the patient, it is very beneficial in the legal process since it displays all the medical problems of a patient. It reduces the chances of misdiagnosis and hence reduces medical errors; therefore, legally, it reduces the chances of a medical professional going to court due to errors committed during treatment.

In addition, the medical professional can still have enough information to explain why different treatment procedures are undertaken. However, the system is disadvantageous based on the fact that it is cumbersome. However, incase the patient attends different hospitals; it becomes difficult to have a comprehensive record that is necessary during legal processes (Post & Harrison, 2006).

PIE charting is a method that is not as popular as other methods. The word PIE basically means documenting of patients records, evaluation, as well as all the interventions. The method came in to being in the year 1984 and was meant to eliminate the care plan that existed initially (Iyer, Levin, & Shea, 2006).

Although PIE charting has got several advantages, the most important benefit in the legal set up is the fact that it is comprehensive as it contains interventions, evaluations as well as the diagnosis. In addition, it is very significant in the legal process due to the fact that evaluation is done systematically. On the other hand, there are disadvantages of PIE charting especially in reference to the legal arena.

For example, the method leaves out some important procedures like the planning process which may be very important in the legal processes. Failure to access some information during the legal process may interfere with the whole process since all information from the initial step is important to help in making legal decisions (American Health Information Management Association & Roach, 2006).

As highlighted in the introductory part, medical records are used for various purposes but are very vital in legal processes. However, despite the fact that all methods try to capture the same information, recording is done differently and in different formats. In consequential, all methods have got particular advantages and disadvantages. More specifically, for legal purposes, the study has illustrated that some methods have got advantages as well as the disadvantages.

For example, while the problem oriented is easier to understand since it contains a problem list, the PIE chart is disadvantageous due to the fact that it omits some specific information that may be important. Therefore, it is explicit that all methods have got advantages and disadvantage which are dependent on the purpose of the medical record as well as on other factors ( PKC Corporation n.d. )

References

PKC Corporation. (n.d.). A Problem Oriented Approach to the Computerized Patient Record. Retrieved December 13, 2010, from http://www.pkc.com/papers/pomr.pdf

American Health Information Management Association & Roach, W. H. ( 2006). Medical records and the law. New York: Jones & Bartlett Learning.

Iyer, P. W., Levin, B. J., & Shea, M. A. (2006). Medical legal aspects of medical records. Tucson: Lawyers & Judges Publishing Company.

Post, A., & Harrison, J. ( 2006). Data Acquisition Behaviors during Inpatient Results Review: Implications for Problem-oriented Data Displays. American Medical Informatics Association , 644–648.

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