3-16. AVAILABILITY AND RELEASE OF MEDICAL RECORDS
a. For the Diagnosis, Treatment, and Prevention of Medical Conditions.
Medical records are used in the diagnosis, treatment, and prevention of medical
conditions. If a patient is scheduled for a contrast study or special procedure, the
medical records will accompany the patient to the radiology department. The radiologist
must have the medical record at his or her disposal so that the patient's history and
condition can be reviewed, and relevant factors, such, as possible allergies,
susceptibility to fainting, etc., can be identified.
THE DUAL ROLE OF ARMY MEDICAL RECORDS MEANS WIDER ACCESS
A service member enrolled in the Army Substance Abuse Program (ASAP) is
administratively attached to the program. This means that he or she cannot be
reassigned for the duration of the program. Because of the dual (medical &
administrative) role of Army medical records, personnel outside the medical
community may have a legitimate need to access information in the records. For
example, a commander who is planning future reassignments may wish to check on
the length of the soldier's participation in an alcohol abuse program. A Company
Commander with a soldier, who is chronically ill, may need to review an excerpt from
the soldier's records relevant to his other area of concern. Generally in the civilian
world, a boss would not have similar access to information contained in an
employee's medical records.
b. For Research. Personnel involved in research have the right of access to a
patient's medical records. They are, of course, bound by the same ethical requirement
to protect the patient's identity (and privacy).
c. For Legal Proceedings. There may be occasions on which records are
required for judicial proceedings. Hospital records may be admissible as evidence in a
court of law, provided the records are duly authenticated and relevant to the issue on
which the court is deliberating. State laws will vary on the issue of admissibility.
d. For Hospital Accreditation. When a hospital goes through the accreditation
process, examiners review medical records to ascertain that they are kept in the
prescribed manner; for example, that lab, x-ray, and other reports are filed, and that the
outcome of scheduled exams is duly annotated. Accreditation is important for a military
facility. The option to function as both a health care and a teaching facility, for example,
is based on having exceeded accreditation requirements, and having the manpower
and the caseload to warrant training.