Medical record

“ Under that statute, a judicial officer determines whether there is good cause by weighing the public interest and the need for disclosure against the potential for injury to the patient, to the physicianpatient relationship, and to the treatment services. It is appropriate to extend limitations on the use of health information to all situations in which the government obtains medical records for a health oversight purpose. ”

“ Duty to preserve medical records by persons in charge of hospital, medical clinic and place of custody
8.— (1) Where a person dies—
(a) while in any hospital or medical clinic for medical treatment or care; or (b) while he is in official custody, the person in charge of the hospital, medical clinic or place of custody, as the case may be, shall preserve all medical records, health-care records and any other document pertaining to the medical treatment or care of the deceased as are in the possession of the hospital, medical clinic or place of custody for such period as may be prescribed. ”

“ Any person in active practice who is not blessed with a most tenacious and particular memory is liable to forget a great many details which, with a record in hand, properly kept, could be brought to his memory and be testified to with absolute truthfulness and conviction. And the record itself, when properly shown to be a book of original entry, is generally receivable in evidence, as a memorandum of the transaction. ”

“ Honored in their day, not unremembered by a few solitary students of the past, their memories are going sweetly to sleep in the arms of the patient old dry-nurse, whose "blackdrop" is the never-failing anodyne of the restless generations of men. Except the lively controversy on inoculation, and floating papers in journals, we have not much of value for that long period, in the shape of medical records. ”

“ After careful examination, the nature of the defect or disease found, is put in the form of a medical certificate which must be signed by at least three of the physicians on duty. It is not within the province of the medical officers to pass judgment on the eligibility of the immigrant for admission. ”

“ If any person whose registration is not legal because of some error, misunderstanding, or unintentional omission shall submit satisfactory proof that he had all the requirements provided by law at the time of his imperfect registration, and was entitled to be legally registered, he may, on the unanimous recommendation of a State board of medical examiners, receive from the regents under seal a certificate of the facts, which may be registered by any county clerk and shall make valid the previous imperfect registration. ”

“ All persons who have made the practice of medicine and surgery their profession or business continuously for ten years, and can furnish satisfactory evidence thereof to the State medical examiners, shall receive a license to continue (ib., s. 3,550) .
Examinations of persons not graduates are made by the State board, wholly or partly in writing, in anatomy, physiology, chemistry, pathology, surgery, obstetrics, and practice of medicine (exclusive of materia medica and therapeutics) (ib., s. 3,553) . ”

“ For those which have respect to the health or to the illness of an individual there is no particular legal form, as a certificate is merely a simple statement of a fact. The only essential condition is that it contains the exact truth, and any departure from this will entail heavy penalties. A statement signed by a registered medical practitioner, distinctly describing the condition of A or B, is all that is necessary as far as the law in England is concerned. ”

“ Do not send written certificates [Pg 20] to third persons as to the result of the examination, unless (1) In an open envelope, having read the certificate to the patient who takes it to its destination; (2) After having received the written consent of the patient so to do.
The payment of the fee by a third person does not absolve from the rule of professional secrecy.
The symptoms and feelings of a patient are sometimes admitted as (hearsay) testimony from a medical witness, especially where the former is dead. Letters from a patient to a medical man containing such statements are not allowed. ”

“ Where the court is, or the police are, in doubt as to the exact age of the person by whom an offence is alleged to have been committed, the certificate of a Government Medical Officer to the effect that, in his opinion, the person has or has not attained a specified age may be given in evidence. ”

“ Where the deceased has been attended during his last illness by a registered medical practitioner, such medical practitioner must sign and deliver to one of the persons required to give information concerning the death, a certificate stating, to the best of his knowledge and belief, the cause of death, which certificate must be delivered to the registrar by such person on giving information concerning the death. ”

“ Pursuant to this statutory authority the Surgeon General issued regulations which detail the manner in which medical examinations shall be held and the type of certificates by which examining doctors and boards shall report their findings and conclusions. As shown by the dissenting opinion below, serious challenges have been made to the sufficiency of the certificate of the medical appeal board as well as to the initial medical certificate in which two doctors certified petitioner to be a mental defective. ”

“ A copy of the medical register for the time being, purporting to be printed and published under the direction of the General Council, is evidence in all courts that the persons therein specified are registered according to the provisions of the Medical Act; and the absence of the name of any person is evidence, until the contrary be made to appear, that such person is not so registered; and the contrary may be shown by a certified copy, under the hand |18| of the registrar, of the entry of the name of such person on the register (17) . ”

“ The preliminary examination of the patients, which was almost always impossible, would, even if attempted, leave the door open for as many errors as the present system. In practice, it was necessary to remain content with the certificates delivered by the medical men who had been in attendance on the patients, and these certificates accordingly acquired capital, decisive importance. Doctor Bonamy ran through the documents lying on one of the tables and gave the Paris journalist some of these certificates to read. ”

“ Unregistered Persons.—No person is entitled to recover a charge for medical or surgical advice or attendance or the performance of any operation or any medicine prescribed or supplied unless he produces to the court a certificate that he is registered ”

“ And in the same year, "The Medical Register for the State of Massachusetts," to be followed in 1879 by "The Medical Register for New England," the eighth edition of which containing biographical notices of practising physicians, a most useful book, was published in 1895. ”

“ Certainly, on some occasions, the examination to which the patient was subjected, in order to ascertain if he were truly a leper or not, seems to have been of the most searching and scrutinising nature. I have already alluded to the strict rules of examination that have been preserved for us in the works of different authors,98 and quoted the method recommended by Guy de Chauliac to be followed by physicians before they remitted suspected patients with medical certificates to the magistrates (cum literis medicorum ad rectores) . ”

“ This branch of the law is also important to the faculty, as they must frequently be called upon to justify the medical certificates which the insurance offices uniformly require before they issue a policy, and it continually involves the very nice question as to what shall or shall not be considered a disease tending to shorten, or endanger life. ”

“ A record is kept of the name, regiment, and company, disease, and number of ward and hammock of each patient admitted, and of all transfers, so that any patient in the hospital can be found, and all the facts in relation to his case learned, in a few minutes. ”

“ No person who shall have commenced the practice of medicine or surgery since January 1st, 1885, or who shall hereafter commence the practice of the same, shall practise as a physician or surgeon for compensation without having obtained a certificate and caused it to be recorded. ”

“ At the beginning of the last decade of the Institute's occupancy of the old building, there were 12 such links; at the time of the move into the new building, the number had grown to 22, each one with a registrar chosen from the Institute's staff of senior pathologists. The separate registries, each working with its own sponsoring organization in medical, dental, or veterinary specialties, are bound together in the American Registry of Pathology. ”

“ No certificate required from any physician or surgeon or medical practitioner is valid unless the signer be duly registered (ib., s. 28) .
A person not registered or licensed, and not actually employed as a physician or surgeon in Her Majesty’s naval or military service, practising physic, surgery, or midwifery for hire, gain, or hope of reward, forfeits twenty dollars for each day of such practice (ib., s. 29) . ”

“ Every legally qualified and registered medical practitioner in actual practice in or near the place where the death in question happened, by the Coroners Act, 1887, may be summoned by the Coroner to give medical evidence as to the cause of that death. Thus medical men may be compelled to practise medical jurisprudence if called upon so to do. With the growth of knowledge and exact observation, the weight which is attached to medical evidence has increased proportionately. ”

“ The registration must be accompanied by visitation. The appointed medical registrar must be a witness to the fact he is called upon to register; and a case once registered should be visited at least once in three months, until recovery or death takes place, when in either case the return of the patient as a lunatic would be cancelled under a certificate to the fact supplied by the registrar. These remarks apply specially where patients are placed out singly. ”

“ A medical certificate meeting the substance of those requirements, in the case of seafarers not covered by STCW, shall similarly be accepted.
4. The medical certificate shall be issued by a duly qualified medical practitioner or, in the case of a certificate solely concerning eyesight, by a person recognized by the competent authority as qualified to issue such a certificate. Practitioners must enjoy full professional independence in exercising their medical judgement in undertaking medical examination procedures. ”

“ Nothing is required (in the absence of any statutory provision to the contrary) to entitle any one to give evidence as a medical witness, than that he has been educated in the science of medicine; and this he may be by study without practice, or by practice without study; it is not necessary that he should be a physician, or have studied for one, nor be a graduate, nor one licensed to practise, nor need he be or have been a practitioner (275) . ”

“ The registries are a living link between the practitioners of the various medical specialties and the staff of the Museum and its successor organizations — first the Army, and then the Armed Forces Institute of Pathology, in the consultation, education, and research which are their common objectives. ”

“ The science, the art, and the correct estimation of the value of Medical Evidence is the province of Forensic Medicine.
It is hoped that this little book will aid the General Practitioner when he is called upon to offer medical testimony, so that the ancient inquest jury especially may fully appreciate the bearing of the technical facts he narrates. Those who pose as “experts,” should ipso facto be themselves authorities on the matter and the manner of bearing testimony. ”

“ A reception order is valid for seven days from its date, unless the lunatic is certified by a medical man to be unfit for removal, when the order is extended until a medical certificate of fitness for removal is obtained, which is valid for three days.
The medical men signing the certificates must not be in partnership, as principal and assistant, or have any direct or indirect interest in the patient or his keeping (16 and 17 Vict. c. 96, sec. 4) . They must make separate visits at different times for the purpose of examination. ”

“ It would be of little avail to speak of all the minute detail, of which there is a tremendous amount in each and every one of these offices and sections of the medical service. The methods of filing correspondence and records alone is wonderful when one thinks of the conditions and number of men involved, and comparatively few mistakes are made. ”

“ A person qualified registers by filing with the county clerk of the county where he practises, or intends to practise, a sworn statement setting forth, if actually engaged in practice, the length of time he has been engaged in such continuous practice; if a graduate of a medical college, the name and location of the same, when he graduated and how long he attended the same, and the school of medicine to which he belongs ”

“ Any bodily or mental infirmity or ill-health which may result from an injury and its necessary treatment in the past and future, all these questions and many more unnecessary to mention may be required of the medical witness. No general rules can be laid down for all such cases. In giving his testimony the medical man must depend in any particular case upon his knowledge, judgment, and experience. ”

“ The medical certificate must contain a statement that it is expedient for the alleged lunatic to be placed forthwith under care, with reasons for making such statement. The certifying medical practitioner must have personally examined the patient not more than two clear days before his reception. In London and other large towns, where an expert opinion is readily obtainable, it is not expedient to resort to such urgency orders. Medical men should be careful how they sign certificates of insanity. ”