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by solace

Is it the patient or the hospital? Can a patient read his or her chart? Or a family member with the permission of the patient?

[kakamegamama]

Re: Who owns Patient's Chart?

I believe the patient owns his/her chart & whomever he/she has designated, with written permission, should have access to it. Doesn't happen very often, but it can.

[morte]

Re: Who owns Patient's Chart?

i believe the institution "owns" the chart...it being the work product of their employees/doctor....however with a few exceptions (psych comes to mind) the patient has a right to see it in its entirety (sp)and get copies, but can be charge a fee for that....

[fultzymom]

Re: Who owns Patient's Chart?

Facility owns the chart. Patients or POA's have access. You don't just hand it over for them to pick through. We have them sign a letter of release et write on it all they want. Then medical records copy the pages they want and mail it to the person. Our facility states we have, I believe, one week to get it copied and sent to whomever requested it.

Leslie

[caliotter3]

Re: Who owns Patient's Chart?

The facility or institution owns the chart. The patient gains access to the chart by providing the institution with a written request. For copies of the chart, the patient makes a written request and pays any fee that the institution charges for administrative purposes. This info is stated in the privacy rights/HIPAA disclosure that institutions provide to patients when they enter into a healthcare relationship with patients.

[miko014]

Re: Who owns Patient's Chart?

Agree - facility owns the chart. We have gotten docs orders before to let pt have access to their chart, but they have to fill out an ROI form for anyone but themselves to look at it, and nobody can without an order. They can have copies after d/c but they have to go through medical records to get them - we can't just pull papers off and give stuff to pts.

I don't know waht the entire rationale is behind all that, but it's even worse now with HIPAA. I always heard that this was partially because of all the medical terms and abbreviations in there - that the pt may not understand everything. That's not to say that we couldn't discuss it with them, but can you see having time to go through every page with them, explain stuff, translate some of those progress notes to English for them, etc? There's an urban legend that a pt was allowed to read his own chart and got really upset re: the note "f/u SOB"...course, that's probably not true, but it does bring up a point...

[caliotter3]

Re: Who owns Patient's Chart?

"f/u SOB" Ahhh, something to make me smile today. Going to make this my secret motto!!!!

[nrsang97]

Re: Who owns Patient's Chart?

Originally Posted by caliotter3

"f/u SOB" Ahhh, something to make me smile today. Going to make this my secret motto!!!!

HAHAHA,

Reminds me of when I was charting on the computer and the phone service guy was sitting there and saw me type "Pt SOB with exeriton, needs assist with ADL's". He said "You are calling your pt a SOB???" I said no it means short of breath, however you shouldnt' be reading over my shoulder while I was charting.

I think that will be my secret motto also.

[Kyrshamarks]

Re: Who owns Patient's Chart?

It actually is dually owned in a manner. the patient legally owns the DATA contained in the chart while the facility owns the physical form of the chart. The pateint has the right to see his chart at any time with or without a doctor present. They also have the rioght to consent for anyperson to read th chart as well. The patient also has the right to demand that any factual errors in the chart be remedied.

[kakamegamama]

Re: Who owns Patient's Chart?

This was actually my intent to say when I first responded. Kyrshamarks said it so well. I know that when my mother-in-law was hospitalized I was given permission to review her chart by her POA, and did so. I've also asked to see other family members, at their request. Sometimes I was greeted nicely by the nurse who I made the request of, sometimes not.