Patients reading their own charts-yay or nay?

mitchsmom · May 19, 2006

Definitely "yay".

BMW10 · May 19, 2006

cancelled response to question: "what errors?" n/a to forum topic

king of codes · May 20, 2006

our policy is yeah, a pt. can goto medical records and order a transcription of the chart after signing a waver stating that it is their responsibility to contact their primary md with medical questions.

unless you want to sue, the facility should have already answered your questions, joe public won't understand the verbage anyway and shouldn't have waited so long to ask. we let any patient have access to them, it seems crazy to have a nurse and patient trying to decipher an md writing.. and undoable to have an MD there for 2 hours of their time as a pt. reads through medical language. To me, at this point, you've got an attorney to do it for you, call me crazy

burn out · May 20, 2006

No way will I allow any patient or family member to read a chart. 1. I don't have time to sit and explain every minute detail that they are going to ask

about. 2. This is an area for the doctor to explain. 3.Most of the time they don't even understand the simple things that I do try toexplain to them let alone a novel about the patient. 4. It is against our hospital policy to give them the chart 5. Let the lawyers handle it. 6. Most of the time the families are not looking to understand but to find reason to file a law suit.

louloubell1 · May 20, 2006

I think the pacients have every right to read there charts. I would read my chart i would want to know what was wornge with me. So i think it should be up to the pacient if they want to read there own charts or not. I could understand if anyone else but you the pacient wanted to read your chart with out your premission.

I apologize in advance, because I'm not normally one of the folks around here that flips out about spelling in posts, but seriously... how can you be a nurse, nursedave907, & you can't spell p-a-t-i-e-n-t? That kind of weirds me out.

Lou

Hoozdo, ADN · May 20, 2006

I am MPOA for both of my parents. Whenever there is a hospital admission for either of them I first establish MPOA. The next thing I do is ask for a doctor's order that I can read the chart. With a doctor's order I can access the chart anytime I want.

I justify this by telling the nurses and doctor, "Let's all save some time and let me read the chart so you don't have to update me everyday." I think if you are a nurse you should be able to read the chart.

I have mixed feeling about a layperson reading their own charts. Most would not know where to even begin and it would bring on LOTS of questions. We barely have time to do our jobs now, let alone explaining medical terminology and translation to basic english of procedures and results of procedures.

firstaiddave907 · May 20, 2006

I apologize in advance, because I'm not normally one of the folks around here that flips out about spelling in posts, but seriously... how can you be a nurse, nursedave907, & you can't spell p-a-t-i-e-n-t? That kind of weirds me out.
Lou

sorry about the spelling error i was trying to do spell check but it was not working right.

BMW10 · May 20, 2006

I apologize in advance, because I'm not normally one of the folks around here that flips out about spelling in posts, but seriously... how can you be a nurse, nursedave907, & you can't spell p-a-t-i-e-n-t? That kind of weirds me out.
Lou

I agree, Lou, and believe you answered your own question.

babiesX2 · May 20, 2006

At my facility, pt's must go through HIM and pay $.10 per page. The medical record it property of the hospital, and as such, I must follow the rules that the hospital dictates. I don't like the idea of a pt or their representative reading a chart because what if they don't understand something. As a PP said, SOB and other abbreviations of that nature could mean big trouble for the hospital (and me!). Plus, under normal working conditions, I don't have time to sit with a pt so they can read their chart.

mshultz · May 21, 2006

Ok, from the ANA website at http://www.nursingworld.org/readroom/position/joint/jtdata.htm:
Access by the Patient: Individually identifiable patient health care information is private and is often sensitive. Therefore, the need to limit disclosure of such information is universally recognized, as is the concept that under most circumstances, only the patient has the right to authorize the release of the information to third parties. However, no such consensus exists on the right of a patient to see his/her own health record. In 1994, 27 states have laws specifically regulating patient access to his/her health record. Some of these laws expressly prohibit a patient from reviewing his/her health record without authorization from the practitioner/health care provider. States with no patient access legislation leave the decision to health care providers. Federal laws granting a right to access exist, but only for specific patient populations. Health care professionals generally acknowledge that the information in the record is the property of the patient. Yet, in many states, access to the information may be denied to the patient. However, there is growing recognition of the fact that the patient's access to his or her records can help the patient become more involved in his or her health care. This can actually improve both the quality of care and outcome of care.

This position statement is dated November 1995, which is pre-HIPAA.

According to the Center on Medical Record Rights and Privacy, Georgetown University:

http://hpi.georgetown.edu/privacy/records.html

"A federal law called the HIPAA Privacy Rule gives you the right to see, get a copy of and amend (correct) your medical record by adding information to it."

An explanation of the information is not a right under HIPAA. Individual states may give patients additional rights, such as access to psych notes, but may not take away patient rights protected by HIPAA.

burn out · May 21, 2006

I am MPOA for both of my parents. Whenever there is a hospital admission for either of them I first establish MPOA. The next thing I do is ask for a doctor's order that I can read the chart. With a doctor's order I can access the chart anytime I want.
I justify this by telling the nurses and doctor, "Let's all save some time and let me read the chart so you don't have to update me everyday." I think if you are a nurse you should be able to read the chart.
I have mixed feeling about a layperson reading their own charts. Most would not know where to even begin and it would bring on LOTS of questions. We barely have time to do our jobs now, let alone explaining medical terminology and translation to basic english of procedures and results of procedures.

Where I work the MPOA would mean nothing unless the patients had been declared mentally incompetent by the physician.

BMW10 · May 25, 2006

burn out seems aptly named. Goodness, what a low opinion of her/his patients' intelligence as well as disregard of their motive to be actively involved in their own or a loved-one's care. Too, burn out's facility appears to have a few outdated policies re: patient and patient-advocate rights. Or, perhaps, burn out has simply overlooked HIPAA rules and MPOA guidelines that give patients very specific RIGHTS to view, copy, even add their own information (to correct or clarify) to the chart and or any record on file. They do not, however, have a right to any on-the-spot explanation or interpretation of what has been charted and most nurses would be well-advised to refer all requests for interpretation to the patient's physician.