Answered By: Michael Jundi
Last Updated: Mar 27, 2020     Views: 1439

The medical chart on a particular patient provides data specific a patient's key clinical data and medical history, such as demographics, vital signs, diagnoses, medications, treatment plans, progress notes, problems, immunization dates, allergies, radiology images, and laboratory and test results.

To me; citation of such a chart in APA could be considered a technical report; where the client/patient IS the subject of research or subject of the problem being studied by the author (Doctor). As in a technical report; suggestions for treatment, facts and conclusions related to the situation are all present in such a record.

 

Pg. 205 in the 6th ed. APA style guide provides more information about technical reporting; but here’s a couple examples of a citation related to medical information from a patient’s chart that does not identify the patient.

 

Physician (Year, Month date [Dictation Date]). Exam [italicized]. City: Facility.

Examples:

Wilson, H. [Henry]. (2014, June 1). Right forearm. Orlando: Florida Radiology Imaging Oviedo.

Wilson, H.[Harriet]. (2014, May 22). Nuclear medicine bone scan. Orange City, FL: Florida Hospital Fish Memorial.

Zaid, A. (2016, April 11). Annual Exam (Record No. 91- 342453). Warrensville Heights: Brentwood Hospital.

 

HIPAA informs on access to medical records, along with stipulations on how this information can or could be shared. From the HHS.gov website (https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html )

What Rights Does the Privacy Rule Give Me over My Health Information?

Health insurers and providers who are covered entities must comply with your right to:

  • Ask to see and get a copy of your health records
  • Have corrections added to your health information
  • Receive a notice that tells you how your health information may be used and shared
  • Decide if you want to give your permission before your health information can be used or shared for certain purposes, such as for marketing
  • Get a report on when and why your health information was shared for certain purposes

Any other types of information identifying a particular patient by name or use of their personal medical records without their authorized permission would in fact be a HIPAA violation.

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