Medical Records: Patient Care And Quality Assurance Are The Only Reasons For Access 

Legal Eagle Eye Newsletter for the Nursing Profession

November 1996

  Quick Summary:  An employee’s grievance over patient-care issues is not a valid reason for an employee to access or copy patients’ records. 

  Caregiving professionals in a hospital need open access to charts of current patients to facilitate treatment, but that need ends when the patient is discharged.

  After discharge, access to patients’ records should be allowed for approved quality assurance studies only. SUPREME COURT OF IDAHO, 1996.

   A hospital must permit relatively open access to patients’ charts and other medical records by the hospital’s professional employees, in the interest of effective patient care, during the patient’s admission to the hospital.

   However, according to the Supreme Court of Idaho, after a patient has been discharged, general access to the patient’s records should be restricted. Access should be allowed only to persons who have good reason and proper authorization to see the records for approved quality assurance studies.

  Even while a patient is receiving inpatient hospital care, according to the court, it is not permissible for a hospital employee to view a patient’s medical records, or photocopy them or make handwritten notes from the records, for the employee’s own purposes, such as trying to substantiate a grievance the employee wishes to pursue with the hospital over patient-care issues.

   If an employee who has access to current patients’ records for patient-care reasons violates a patient’s right to confidentiality, by copying or just reviewing patient’s records for an impermissible purpose, the employee may be terminated for misconduct, the court ruled.

   Investigation of patient-care matters is the job of a hospital’s quality assurance department. The court said that the quality assurance department would be more able than an individual employee to minimize the potential for encroachment on patients’ rights of privacy and to work to improve the overall quality of patient care. McAlpin vs. Medical Center, 921 P. 2d 178 (Idaho, 1996).