Access to medical records

Nurses General Nursing

Published

A nurse is probably trying to *** me because the hospital screwed up pretty badly and so now he claims he cannot let me review the last note the physician/resident wrote during rounds or review lab work with me. It literally takes 10 minutes. He said they make even patients use mychart. 

I am listed on the paperwork they provided for POA as an alternate. The way the document is worded is that alternates have access to medical documents and patient records immediately if he cannot make decisions. This is from the state and the hospital had us fill it out.
 

I do know that we are pissed about multiple botched procedures. Like I am pretty forgiving but I honestly feel like they almost killed him. I have a tad bit feeling that day shift RN may have made notes and hid them from the patient mychart as facility allows nurses to hide notes. 
 

I do feel better about the prognosis as it probably is fixed and I am impressed with the attending note analyzing some potential fever causes. 

Anyway, is this a policy at your hospitals? That patients and their POAs cannot access medical records or review it with the nurse? they are claiming that patients cannot review the notes or lab work either. No policy provided.


I'm threatening tomorrow to make the resident come down in the morning and read off every lab value to me as the nurse said he could see if the resident would review it with me.

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Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.

Yes, generally speaking, for inpatient stays, the hospital usually has x days to provide medical records when they're requested (I think it's up to 30 days). There is no expectation that records are available immediately. That said, it's good practice for patient-centered care, to let a patient see notes if they want.

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You have to go through appropriate channels to get medical records.  This was little hard for me to understand, but if you want medical records and are the POA you can go to the medical records office and request the records or you can go into my chart and see some things.  
 

But I don't share notes and allow people to view charts when I have them pulled up.  

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Well, turns out it is not policy and they do allow people to view charts with healthcare records.

I am concerned about some of the responses here though. It doesn't seem like you guys would be providing adequate care. This is probably laws have changed and EMR release the records sooner. 

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Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.
ApplePineApple said:

Well, turns out it is not policy and they do allow people to view charts with healthcare records.

I am concerned about some of the responses here though. It doesn't seem like you guys would be providing adequate care. This is probably laws have changed and EMR release the records sooner. 

There are only 2 responses. What about my response has you concerned or makes you think I don't provide adequate care? I'm very aware of laws regarding patient records, and there is no law that requires inpatient records to be available on-demand, immediately. Did you miss the part where I said that it's good practice to allow patients to view their chart/records anyway, if they ask? I would do that for patients if they requested. I would not, however, do that for an MPOA (unless it was the parent of a minor child) - they can go through the proper channels.

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Specializes in orthopedic/trauma, Informatics, diabetes.

we use EPIC where I work and literally everything is released immediately to pt via MyChart. Certain results are not released d/t something like a sensitive dx or one that needs to explained in context. We may hide notes, mostly only pysch or, again, sensitive info that should be delivered in person. 

I am a HCPOA for both of my kids and I can see everything in MyChart. 

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Specializes in Community health.
ApplePineApple said:

"This  is probably laws have changed and EMR release the records sooner"

I couldn't follow this sentence and I'm not sure why you think the people who answered you aren't providing good care? 

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Specializes in Psych, Addictions, SOL (Student of Life).
ApplePineApple said:

Well, turns out it is not policy and they do allow people to view charts with healthcare records.

I am concerned about some of the responses here though. It doesn't seem like you guys would be providing adequate care. This is probably laws have changed and EMR release the records sooner. 

When my son was born he was very ill with intracable seizures He was in the NICU for 20 days then the Seizures miraculously resolved. It was the policy in that hospital that only the attending physician could review labs with parents and provide explanations. This was to insure that the parents fully understood what the lab results meant. 

This has also been the policy at every hospital I have worked and no family member POA or not had complete unrestricted  access to to a nurses notes.

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ApplePineApple said:

Well, turns out it is not policy and they do allow people to view charts with healthcare records.

[...]

How exactly is this access granted?

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Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

If notes and results are chosen by a provider to be hidden from MyChart, I certainly don't feel it's my place to open up the chart on demand and show it to someone.  I agree with the person who told you that like everyone else you need to use MyChart.  If you feel something is hidden there should be channels to get you access to the complete record.

I personally have never written a note that I've hidden and not sure I would know how.  But often things need to be hidden until the MD can talk to the patient or POA about it.  Such as a radiology or pathology report that shows a mass with mets, etc.

 

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Specializes in Geriatrics.

You attract more flies with honey. You probably have every right to be upset, but they have 30 days to produce the records. In this time who knows what can happen to your loved one. Nobody is going to help you if you go in blazing saddles and accuse,threaten/ intimidate. Does it work when your patients do that to you? Try to remain calm, make a friend at the facility, talk to them on the level and approach it with "I had a few questions, do you think you can help me out? ". You will get a lot further. I don't recommend going through toe to toe with the resident. Medical residents have been through a lot of this type of behavior from nurses and other physicians, they are already defensive from the get go. It can be tough as a new grad doctor to prove your worth in a hospital environment. Take a deep breath, and realize that you do know a lot, but their are other colleagues in the facility who probably know a lot too.

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ApplePineApple said:

I am concerned about some of the responses here though. It doesn't seem like you guys would be providing adequate care.

I'm pretty sure the attitude displayed in this statement is why you are getting push back from the staff. 

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