Can I read my own chart?

sjoe · Nov 12, 2002

Some hospitals would put up roadblocks to a timely review of your chart, others would not. When I was a DPOAHC for a dying friend (at a Kaiser facility--and not, that is not what killed him), I had no trouble reading his chart. The nurses were so busy with their 1-10+ staffing and were glad that I was doing most of his care, that they just pointed to the chart on their way by.

Keeping up on it was how I noticed, for example, that the night nurses weren't giving him his night antibiotics, since they had to be crushed up and given with applesauce and they simply did not have the time.

So, when I came in in the morning, I'd review whatever meds had been missed and give those that would be useful, since I had the time. It's also how I knew he hadn't simply slipped into a coma one night, when I noticed that a nurse had given him a VERY large dose of MS to keep him quiet and free from agitation (he was out for over 24 hours--it did him a lot of good). (I had left orders that he was not to experience the sensation of pain, so there was no limit on the amount of MS that could be given.)

If there's no rush, the easiest thing to do is to request your own copy of your chart from the Records Department, as I usually have done. Also I have copies of xrays, MRIs, etc. They can charge you so much a page to do the coyping (and it cost me about $9 per xray sheet after the first set of copies), and it may take a week or so.

Having your own copies of everything makes it very easy to get second opinions, attend appointments with no chance of hearing "they didn't send up your chart," etc.

Besides simple misunderstanding of the data, one of the reasons facilities want viewing of an actual chart to be supervised by an employee, is so that people can't just remove items and pages they don't happen to like or that they want to have for themselves, or write in stuff pretending to be employees, etc.

Doesn't it seem strange, or at least redundant, to anyone but me that some, not all, facilities require a release of information to give this data to the patient who requests it? Duh!

nurseman · Nov 12, 2002

As far as I know it the chart belongs to the institution and the patient can view it or have copies made (for a small fee). Last hospital I worked at the head nurse had to go over the chart with the person during regular business hours.

Guideline for Ontario Nurses in independent practice

2) A member shall provide copies from a client health record for which the

member has primary responsibility to any of the following persons on

request:

1. The client.

2. Apersonal representative who is authorized by the client to obtain

copies from the record.

3. If the client is dead, the client's legal representative.

4. If the client lacks capacity to give an authorization described in

paragraph 2

http://www.cno.org/index_publications.html

mattsmom81 · Nov 13, 2002

I don't mind a patient or family member reviewing their chart but it frequently becomes a huge headache...as we are all so busy and who has time to interpret medicalese and hundreds of items for a layperson? It can become a major ordeal.

My favorite copout here (LOL) is to call the nursing supervisor...and if she says show them the chart, I say 'Well, then will you supervise? I do not have time nor does my staff. " Often she will say "I don't have time either" and then SHE refers the patient/family to medical records for supervision and/or a copy of the chart.

When I was charge at the desk sometimes I would let a patient review their record in front of me there...but if the questions got too much I had to put the nix to it. We can only do so many things at one time, ya know??

Medically trained patients or family members I gladly allow to inspect the chart..unless there is a problem voiced by administration then I let them handle it.

Plus I feel the doc is ultimately responsible for a lot of the info in the chart, although they turf all the explanations and interpretations of tests to the nurse so very often don't they .

charissa · Nov 13, 2002

At our facility i was repremanded initially when a coworkers husband was hospitalized on our floor and she read his chart without him first giving permission. My LPN coworker noticed, stopped her and made a comment to the supervisor to get it on record in case an incident arose later(He was in for r/o viral meng. and they tested for syph.) as some things might be upsetting to her. An incident arose, and i would not allow her to view the chart again until he gave permission, but he was sleeping and she didnt want him distrubed so she made a complaint. At first i was in the hot seat but i stuck to my guns even when the she had the dr call and give me an order to let her read it i informed him the pt had to give permission first. After a big freakin ordeal i finally got a half hearted half apology and was vindicated, but with the emphasis they pretend they put on confidentiality it was upseting that it was so hard to get the facility to recognize the legal standards. I think a big reason for wanting the dr there is because some things that are regular assessment of dx terms may appear offensive to some laypeople who dont recognize their exact meaning or use, and that most of the time they would not be able to really understand much of the material. I agree with the comment about not having time to go over every detail in the middle of a shift i have had that experience with families who did get access to their family members chart

mattsmom81 · Nov 13, 2002

Good point Charissa...I neglected to mention that we need to make sure the PATIENT wants family to see the chart...sometimes they do NOT. :)