Can I read my own chart?

  1. I am going to have surgery soon. Do I have a right to read my own chart while I am in the hospital? A collegue said that I have a right to read my chart on a "need to know" basis. I replied that I need to know everything! Does my nurse friend have a right to read my chart if I give my permission? I was in my Doc's office last week and asked the medical assistant if I could see my chart and she said "It's better if the Doctor goes over it with you" I had a lot to talk about with the doc and so I didn't bother. I wasn't in an assertive mood but I was tempted to argue with the MA that it was MY CHART! Does anyone know? Thanks in advance.
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    About shavsha

    Joined: Aug '00; Posts: 70; Likes: 7
    med/surg staff nurse


  3. by   Tweety
    It's a sticky situation. We allow patients or next of kin to read the patients chart only with a doctor's order. Preferably in the presence of the Dr. If the presence of the MD is not possible, we take them to a quiet place, stay with them, but decline to answer any questions related to diagnosis, result interpretation, etc.

    I'm not sure if we let friends read a patients chart, but with an MD order, and written permission from you, it just might be done.

    But if you trust your Doctor and know what questions to ask, then reading the chart is not all that necessary. But I probably would want to read my chart too.

    Everyone has a right to her/his medical records by law.
  4. by   Dplear
    You do have the legal right to read your own chart as well as get a copy of it provided to you if you ask. Your chart/medical record actually belongs to you. If you ask to read they cannot refuse you acess to it nor if you authorize in writing someone to see it cam they say no, and the doctor does not have to be present when you see it. This has been brought up many times in our hospital with partents wanting to see thier kids chart and we have to oblige them per the legal department. to do so is violating Federal law.

  5. by   MK2002
    Yes, you can do it. Just ask nicely, and if that does not work, then hold your ground.

    Several years ago I saw a few doctors for a chronic problem. I kept wondering what they were writing, especially since on the second, third, fourth visits there seemed to be no logic to what they told me. Eventually, I had enough. I told the receptionist at one office that payment would be withheld until I received a copy of my chart. My request was honored immediately.
  6. by   Q.
    You are entitled to read your chart. You may have to go through whatever channels they have in their organization, but you WILL get a copy of it.

    I'm not sure how it would be handled on an inpatient surg unit if you gave permission to a nurse friend to come and read it though....
  7. by   almostanurse
    yep, you can read it. It is your chart and belongs to you. mostly they suggest the doc being present so an explanation to any questions can be talked about, and because most lay people dont understand the abreviations ect... used in the chart.
  8. by   J-RN student
    Good to know!
  9. by   Q.
    Originally posted by almostanurse
    It is your chart and it belongs to you.
    I'm actually not sure this is entirely accurate. I remember learning somewhere, whether it was a legal conference or from my insurance days, I can't remember, but the chart is actually the originator's property, which is why, for example, if you chart contains notes originated from your hospital stay at XYZ Hospital, but in the record are also notes from a psych stay at ABC Hospital, XYZ Hospital cannot release ABC Hospital's notes without contacing ABC Hospital, or something.
    I've always wanted to read a copy of my chart from my hospital stay when I had my son. Just curiosity really. Knowing what I know now, medical wise, I think it would be an interesting read.

  11. by   ?burntout
    You have the right to view your chart, but like others have said, usually you are to review it in your doctors presence in a hospital or MD's office..
    At the hospital I work at-you may review your records after signing a "release of info" permit...not sure how it works at other facilities.

    We have had certain family members request to see a patient's chart and they are not allowed without permission from the patient and the MD..our MDs will write an order that "Pt's daughter/son may review the chart"..We will sit in there with them while they read-but I do not answer any questions-I tell them that the MD needs to answer any questions that they have...

    I have to say that your "nurse friend" should not read your chart-in my opinion that would violate your confidentiality....What is she saw something that you did not want shared???? Just a thought...She might would need written permission from you and a MD order???
  12. by   SDNURSE
    Just wanted to add some additional info. Under the Health Insurance Portability & Accountability Act of 1996 (HIPAA) this federal law requires:

    HIPAA Patient Rights

    1. Right to inspect and review their own record.
    2. Right to receive a copy of their medical record.
    3. Right to request an amendment/correction of their record.
    4. Right to add supplemental information to the record.
    5. Right to Restrict use/disclosure of information.
    6. Right to give consent before information is released for reasons other than treatment,payment, or healthcare operations.

    Even though some parts of HIPAA are not in effect yet, many healthcare facilities are already taking steps towards compliance.
    The final Privacy Rules Compliance date is April 14, 2003.
  13. by   Dr. Kate
    The information contained in the record is yours. The physical record belongs to the healthcare facility and access can be regulated by policy. So, that means you have to abide by the policy of the facility to get access but they cannot deny you access.

    Had a situation this weekend, Sunday morning (it seems like these things never occur to people other than on Sunday morning of a 3 day weekend,) where the family wanted to take the chart of a patient who was leaving AMA to the next doctor to care for her. Had to go into the physical record versus information distinction, as well as permissions, confidentiality, etc. I am beginning to believe there isn't a lawyer or physician family member associated with that hospital that has a clue about confidentiality. But that's another issue.
  14. by   sjoe
    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!
    Last edit by sjoe on Nov 12, '02