even more than hospital licensure laws and regulations, they may be keyed to a paper record.

For example, Illinois' long-term care facility licensure regulations require that (1) resident records be written in ink or typed and (2) all physician orders, plans of treatment, Medicare and Medicaid certifications and recertification statements, and similar documents have the original written signature of the physician. Use of a rubber stamp signature, with or without initials, is not permitted. In addition, resident records must contain a "physician's order sheet," a "medication sheet," and "treatment sheets," implying that a manual record must be maintained.17

State licensure requirements for nonhospital institutional providers exhibit the same lack of national uniformity in standards for patient records exhibited by state hospital licensure requirements. In addition, similar concerns regarding obsolete and ambiguous laws and regulations arise in state licensure requirements for institutional providers other than hospitals.

State laws and regulations applicable to physicians, nurses, and other individuals licensed to provide health care typically contain an express or implied obligation of confidentiality with respect to patient confidences and, in some statutes or regulations, with respect to patient records. Willful or negligent breaches of confidentiality may constitute grounds for professional discipline.18

The canons of ethics of a profession may be incorporated into a state's licensure requirements, usually by a provision in a licensing act that makes "unprofessional conduct" grounds for professional discipline. 19 The 1989 publication Current Opinions of the Council on Ethical and Judicial Affairs of the American Medical Association contains detailed guidelines on computerized patient databases.20 These may be impliedly incorporated into the statutes and regulations governing licensure of physicians in some states.

Medicare Regulations

To participate in the Medicare program, a provider must meet the applicable Medicare conditions of participation. The conditions of participation for hospitals include requirements for medical records but do not include


77 Ill. Admin. Code §300.1810 (1985).


See, e.g., 111 Ill. Ann. Stat. ¶4400-22.30 (Smith-Hurd 1990 Supplementary Pamphlet).


See, e.g., 52 Oreg. Rev. Stat. §677.188 (1989); Utah Code Ann. §58-12-35 (1990).


American Medical Association (AMA), Chicago, Illinois. Although it may not be practical to implement all of the AMA's guidelines, it should be recognized that these guidelines are some of the most detailed, ethically sensitive standards for computerized patient databases that have been developed to date.

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