The following opinion is presented on-line for informational use only and does not replace the official version. (Mich Dept of Attorney General Web Site - www.ag.state.mi.us)



STATE OF MICHIGAN

FRANK J. KELLEY, ATTORNEY GENERAL


Opinion No. 6819

September 28, 1994

HOSPITALS:

Records of patients kept by physicians and hospitals

Section 20175 of the Public Health Code provides that a hospital may not permit a doctor, even with the agreement of the patient, to change patient medical records unless the change is a supplementation or correction that does not conceal or alter a prior entry.

Honorable Michael J. Bouchard

State Senator

The Capitol

Lansing, Michigan

You have asked if section 20175 of the Public Health Code, MCL 333.20175; MSA 14.15(20175), prohibits a hospital from permitting a doctor, with the agreement of the patient, to change patient medical records. That section pertains to patient records and provides, in part:

(1) A health facility or agency shall keep and maintain a record for each patient including a full and complete record of tests and examinations performed, observations made, treatments provided, and in the case of a hospital, the purpose of hospitalization. . . .

(2) A hospital shall take precautions to assure that the records required by subsection (1) are not wrongfully altered or destroyed. [Emphasis added.]

Section 20175 does not indicate whether it is wrongful for records to be changed if the doctor and the patient agree on the alteration. As the term "wrongfully altered or destroyed" is not defined in section 20175, we must look to other statutory provisions. Statutes that relate to the same subject matter should be construed together, particularly when they were passed in the same legislative session. Reed v Secretary of State, 327 Mich 108, 113; 41 NW2d 491 (1950).

Subsection (2) was added to section 20175 by 1986 PA 174. In the same year, the Legislature, in 1986 PA 184, added section 492a to the Michigan Penal Code, MCL 750.492a; MSA 28.760(1).

Section 492a imposes criminal penalties for misconduct concerning medical records, as follows:

(1) Except as otherwise provided in subsection (3), a health care provider or other person, knowing that the information is misleading or inaccurate, shall not intentionally, willfully, or recklessly place or direct another to place in a patient's medical record or chart misleading or inaccurate information regarding the diagnosis, treatment, or cause of a patient's condition. . . .

(2) Except as otherwise provided in subsection (3), a health care provider or other person shall not intentionally or willfully alter or destroy or direct another to alter or destroy a patient's medical records or charts for the purpose of concealing his or her responsibility for the patient's injury, sickness, or death. . . .

(3) Subsections (1) and (2) do not apply to either of the following:

 

 

(b) Supplementation of information or correction of an error in a patient's medical record or chart in a manner that reasonably discloses that the supplementation or correction was performed and that does not conceal or alter prior entries. [Emphasis added.]

Construing sections 20175 and 492a in pari materia, it is apparent that the only circumstance in which it would not be wrongful to change a patient medical record is if the change is a supplementation or correction that does not conceal or alter a prior entry. In addition, section 492a of the Penal Code clearly prohibits a doctor from changing hospital or other patient medical records unless the change is a supplementation or correction that does not conceal or alter a prior entry.

OAG, 1977-1978, No 5125, pp 454, 455 (May 30, 1978), previously addressed the purposes of medical records as follows:

While the main purpose of the medical records is to document the course of a particular patient's illness and medical treatment, it must be recognized that medical records may serve many other purposes. Hospital and medical personnel are able to use medical records to evaluate, review and study patient care generally in their institutions. Further, medical records can provide clinical data for research, study and education. They also assure continuity of care should the patient be readmitted. 4 Gray, Attorney's Textbook of Medicine, Sec. 179.10, "Purposes of the Medical Record."

Additionally, the completeness of medical records is a concern when dealing with public health issues such as contagious disease control, or competency and licensing of health professionals, and when dealing with personal injury, malpractice, workers' compensation, insurance, or other legal matters. To allow willful, undetectable changes in medical records, even with the consent of the patient, would adversely affect the necessary reliance on the completeness of medical records.

It is my opinion, therefore, that section 20175 of the Public Health Code provides that a hospital may not permit a doctor, even with the agreement of the patient, to change patient medical records unless the change is a supplementation or correction that does not conceal or alter a prior entry.

Frank J. Kelley

Attorney General