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Give us our medical data!

Posted

http://www.cnn.com/2010/HEALTH/01/14/medical.records/

"For five days as her husband lay in his hospital bed suffering from kidney cancer, Regina Holliday begged doctors and nurses for his medical records, and for five days she never received them."

I didn't know this part:

"Your doctor doesn't have to give you access to everything in your record. For example, your doctor doesn't have to give you access to information he or she thinks might cause you or someone else substantial harm, says the senior health information privacy specialist at the Department of Health and Human Services.

"Some states allow even more information to be kept from a patient. For example, the New York Department of Health Web site says doctors may deny you access to "personal notes and observations" they've made in your record."

As a medical transcriptionist, I've seen some things that I think might upset the patient were he/she to read it, but I guess I didn't realize they could just keep you from seeing it, period.

classicdame, MSN, EdD

Specializes in Hospital Education Coordinator.

I still think I can decide what will or will not harm me and would get a lawyer to assist me. Sounds like a cover up to me.

What also concerns me...and was not the subject of this particular article...are cases I've heard of where an identity thief's medical information gets mixed into their victim's medical information. Then the hospital will not let the VICTIM see their own medical records for fear of violating the thief's privacy. Awgh! :mad:

areawoman

Specializes in Midwifery, women's health. Has 4 years experience.

What also concerns me...and was not the subject of this particular article...are cases I've heard of where an identity thief's medical information gets mixed into their victim's medical information. Then the hospital will not let the VICTIM see their own medical records for fear of violating the thief's privacy. Awgh! :mad:

I think a thief gives up their right to privacy the second they steal someone else's identity!! That is horrifying!

I still think I can decide what will or will not harm me and would get a lawyer to assist me. Sounds like a cover up to me.

My state is one where a provision is written into the privacy laws that you have a right to review and get copies of your medical records except for portions that the attending physician(s) feels may be harmful for you to read. That has to be documented in the record by the physician (including the reasons why s/he thinks that). If the client really insists, the hospital is required to make those portions of the record available to a third party chosen by the client as her/his representative. This mostly comes into play in cases of psychiatric records. It's not a "cover up." It's about whether particular individuals are capable of dealing with seriously negative information about themselves.

My state is one where a provision is written into the privacy laws that you have a right to review and get copies of your medical records except for portions that the attending physician(s) feels may be harmful for you to read. That has to be documented in the record by the physician (including the reasons why s/he thinks that). If the client really insists, the hospital is required to make those portions of the record available to a third party chosen by the client as her/his representative. This mostly comes into play in cases of psychiatric records. It's not a "cover up." It's about whether particular individuals are capable of dealing with seriously negative information about themselves.

sigh....it still has the possibility of a "cover up" and is definetely "nannyitis"

VICEDRN, BSN, RN

Specializes in ER. Has 5 years experience.

I am not surprised that patients are being advised to be more aggressive about their records. Medical records and data are, under our current system, purchased products and they belong to the patient.

The patient should always have their records immediately available to them provided that they pay any appropriate costs for reproduction of copies and that they provide a reasonable period of time for the reproduction of the records.

BrnEyedGirl, BSN, MSN, RN, APRN

Specializes in Cardiac, ER. Has 18 years experience.

I understand needing to get medical records in a timely manner,...but the pt was transfered to another facility and they couldn't treat his pain because they didn't know what was in his system? Really? Transferring records with the pt to another facility, along with the pt,.is totally different from handing records over to a family member. This is or should be done with every transfer, every time. I work ER and get transfers from other facilities every single shift,..we always get a phone call to the Dr, report to the nurse and records,...and we would never go 6 hrs without treating pain! This article sounds a bit extreme to me,....perhaps written by someone not in the medical field who really doesn't have a clue what is going on,...as usual.

i would be checking with the ambulance crew/company.....

Ginapixi, BSN, RN

Specializes in L&D, Hospice. Has 30 years experience.

all i can think of is: it is not the land of the free any more! so let us change it and make it the home of the brave so it will eb the land of the free again!

insurance and other health care agencies do not have the good of the patient in mind as their first and foremost goal; if we let them continue.....

'nough said

country mom

Has 16 years experience.

Transferring a patient without providing needed hand-off information is an EMTALA violation. The transferring facility bears the responsibility for providing the receiving facility with the information necessary to provide continuity of care. This would include any medications that the patient has received during his/her treatment. Seems odd to me that the woman in the story had to "go back to the other hospital" to get his records. That should have been part of the information given in the transfer of care, which the patient/POA agrees to when agreeing to the transfer.

if she was given enough patient education about her husband's condition then there wouldn't be any reason for her to demand for medical records. However, the first hospital is still at fault for not coordinating with the facility the patient was to be transferred to.

Health providers are bound by the HIPAA privacy rule so they seem to be hesitant in releasing medical records. But they shouldn't use this rule from doing their jobs, especially when other medical professionals need these records for further treatment.

if she was given enough patient education about her husband's condition then there wouldn't be any reason for her to demand for medical records. However, the first hospital is still at fault for not coordinating with the facility the patient was to be transferred to.

Health providers are bound by the HIPAA privacy rule so they seem to be hesitant in releasing medical records. But they shouldn't use this rule from doing their jobs, especially when other medical professionals need these records for further treatment.

a wee paternalistic? we need no reason, the info is ours....

Orca, ASN, RN

Specializes in Corrections, psychiatry, rehab, LTC. Has 25 years experience.

This mostly comes into play in cases of psychiatric records. It's not a "cover up."

Having worked on several mental health units, I can see the sense in this. Some patients are in complete denial about their problems, and some have even threatened retaliation if they get a diagnosis that prevents them from getting certain jobs, benefits, etc.

Zookeeper3

Specializes in ICU, ER, EP,. Has 17 years experience.

a wee paternalistic? we need no reason, the info is ours....

Actually, the chart is hospital property. Any patient may obtain a copy of it by appearing at medical records (or thier power of attorney), filling out a form and paying the copy fee. Fees are waived under financial conditions.

Sooo, yes you may see the hospitals information on your stay after following the designated protocol. Sorry, but you do not own your information, but are allowed access to it.

FYI, a patient requires a MD order if they wish to read their chart while inpatient in my facility.

Actually, the chart is hospital property. Any patient may obtain a copy of it by appearing at medical records (or thier power of attorney), filling out a form and paying the copy fee. Fees are waived under financial conditions.

Sooo, yes you may see the hospitals information on your stay after following the designated protocol. Sorry, but you do not own your information, but are allowed access to it.

FYI, a patient requires a MD order if they wish to read their chart while inpatient in my facility.

read carefully, i didnt say the CHART was ours, i said the info was.....we have a right to know it, and if we pay a reasonable fee to have COPIES of it.

I started looking around to try to get a better idea of what happened.

http://www.npr.org/templates/story/story.php?storyId=120028213

"A spokeswoman for that hospital says, for privacy reasons, it can't speak about a specific patient, but that it routinely sends records with a patient who's being transferred to a new hospital.

"But Regina Holliday said that didn't happen, and when Fred arrived at the new hospital, nurses there scrambled to find someone at the old hospital who could provide the records. And that as a result, Fred went several hours without treatment or his pain medications. (A spokesperson for the new hospital says it's not unusual for a patient to be transferred without up-to-date records.)"