[Furoffire]

I am fresh out of hospital orientation and the law is that the patient can read or have copies of their charts BUT you have to call medical records, they come and bring a release for the patient to sign. Yes the argument is that it is thier body but the records belong to the hospital. So just follow the steps of the law for your place of employment. Fluffy

[NrsJena]

Originally Posted by multicollinarity

I believe it is the patient's fundamental right to read his/her chart or a designated rep. That said, I do not believe they are entitled to medical interpretation at their leisure while they read the chart. I don't think the doctor should be required to be there while they read the chart - come on, they are as busy as we are. I think the patient or rep should be able to read the chart with a clerk present from medical records. If they wish to have the chart explained, then they can make an appointment with the doctor. In short, they have a fundamental right to read their records but that doesn't mean they have a fundamental right to instant interpretation on demand from busy professionals.

As a fellow nurse: I agree with you whole heartedly. In this particular case- the discharge planning from SS was nonexistant. My mom was terrified and completely freaking out as he was put on the rehab floor and she recieved a MESSEGE that he was to be discharge the day after discharge from ICU. Noone took the time to explain anything to her- and she naturally assumed the worst. Per hospital policy- I was not permitted to transfer or ambulate my dad as it was after PT hours. The nurse in this case was very understanding and more than willing to help another nurse clear up the situation with a few simple answers. At that time- I'm sure I was much easier to deal with than my terrified mother!

[firstaiddave907]

I think the patients have every right to read there charts. I would read my chart i would want to know what was wornge with me. So i think it should be up to the pacient if they want to read there own charts or not. I could understand if anyone else but you the pacient wanted to read your chart with out your premission.

[HappyNurse2005]

We asked for, and received from Medical Records (weeks post-discharge), copies of her OP notes and progress reports so we'd have them available for the consulting specialist. We were surprised to discover how many errors had been entered into the record...and how impossible it would have been to make appropriate corrections weeks later

what types of errors?

[mitchsmom]

Definitely "yay".

[BMW10]

cancelled response to question: "what errors?" n/a to forum topic

[king of codes]

our policy is yeah, a pt. can goto medical records and order a transcription of the chart after signing a waver stating that it is their responsibility to contact their primary md with medical questions.

unless you want to sue, the facility should have already answered your questions, joe public won't understand the verbage anyway and shouldn't have waited so long to ask. we let any patient have access to them, it seems crazy to have a nurse and patient trying to decipher an md writing.. and undoable to have an MD there for 2 hours of their time as a pt. reads through medical language. To me, at this point, you've got an attorney to do it for you, call me crazy

[burn out]

No way will I allow any patient or family member to read a chart. 1. I don't have time to sit and explain every minute detail that they are going to ask
about. 2. This is an area for the doctor to explain. 3.Most of the time they don't even understand the simple things that I do try toexplain to them let alone a novel about the patient. 4. It is against our hospital policy to give them the chart 5. Let the lawyers handle it. 6. Most of the time the families are not looking to understand but to find reason to file a law suit.

[louloubell1]

Originally Posted by nursedave907

I think the pacients have every right to read there charts. I would read my chart i would want to know what was wornge with me. So i think it should be up to the pacient if they want to read there own charts or not. I could understand if anyone else but you the pacient wanted to read your chart with out your premission.

I apologize in advance, because I'm not normally one of the folks around here that flips out about spelling in posts, but seriously... how can you be a nurse, nursedave907, & you can't spell p-a-t-i-e-n-t? That kind of weirds me out.

Lou

[Hoozdo]

I am MPOA for both of my parents. Whenever there is a hospital admission for either of them I first establish MPOA. The next thing I do is ask for a doctor's order that I can read the chart. With a doctor's order I can access the chart anytime I want.

I justify this by telling the nurses and doctor, "Let's all save some time and let me read the chart so you don't have to update me everyday." I think if you are a nurse you should be able to read the chart.

I have mixed feeling about a layperson reading their own charts. Most would not know where to even begin and it would bring on LOTS of questions. We barely have time to do our jobs now, let alone explaining medical terminology and translation to basic english of procedures and results of procedures.