Giving Health Records to Patients

All Americans have a legal right to see and obtain a copy of their health records.  This is called “right to access” a term the Department of Health and Human Services uses to explain the law.  Any healthcare provider, (doctor, hospital, rehabilitation clinics, nursing homes) is required to provide these documents to their patients.

The good majority of people in the United States have not taken advantage of this provision.  I recently asked our pediatrician to supply a copy of my son’s medical record.  They have not yet gone to Electronic Medical Records, so the nice lady at the front desk simply copied my child’s chart and handed me the information.  She said the doctor was “old school” and was not willing to go with newer technology.  Fair enough, I thought.

Busy parents need to be able to keep track of their own and their children’s doctor visits.  Having this information gives them a leg up to monitor chronic conditions and also stay up to date on wellness programs.  Electronic health systems enable someone to communicate with their treatment teams easier, faster, and safer than traditional methods like my doctor uses.

Medical professionals should help spread the word about the availability of patient’s rights.  The government has a good sampling of literature, videos, and pamphlets that explain ways to obtain your records.

Who owns your medical record?

Many think that their medical records are their own property.  But in reality, the records belong to the doctor or hospital that made them, not you.  This is true with dental records and nursing home records as well.  The “information” in the medical records does belong to the patient, and they have the right to see that information.  The records should include any treatment or procedures as well as something that went wrong as doctors have a legal duty to disclose this in the chart.  The information should be accurate and the provider is charged with keeping it private.

Are they confidential?

In most cases the medical records are confidential.  Certain exceptions do apply:

  • Other doctors that give you medical care (specialists)
  • An attorney, if you give permission
  • A court can rule to give other people in a lawsuit access
  • Health insurers often need access to provide insurance
  • Some employers if you agree to let them see your records

Electronic Medical Records have fundamentally and culturally changed the way patients are involved in their own health care and well-being.  The introduction of this technology is allowing patients to have information they need to make informed choices.  Until now, patients were unaware why they were referred to a specialist, or what is being said about them.  Allowing easy access to these records is a pre-requisite to empowering the patient to be able to take control of his medical care.

Through patient portals and encrypted email, patients can now navigate through their records and have access to patient education linked to diagnosis which helps explain medical terminology for better understanding of a particular condition.  My pediatrician might never become part of this transformation, but those around him are utilizing the tools available to better their practice and involve the patient in his own care.

 

Iron Comet Consulting is a Mckesson Platinum certified reseller, medical IT firm and medical billing service based in Stockbridge, Georgia. Our products combine the clinical with the financial to improve workflow and revenue capture. Mckesson’s Medisoft Clinical is a complete physician practice optimization solution. For more information, please visit http://www.ironcomet.com

 

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