Who owns Patient's Chart?

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Is it the patient or the hospital? Can a patient read his or her chart? Or a family member with the permission of the patient?

Specializes in Medical/Communicable Ward.

the chart would have not existed if there were no patient and almost everything in the chart is about the patient. the patient owns the chart but i never said he could take it. he can only have a copy of it if he requires or he has the right to have any incorrect information in it corrected. the chart can be used as medical / nursing history by the patient which would be very useful if he transfers to another institution (specially if it is in another region).

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What I don't understand is why do people want the chart in the first place. What do they think they are going to find? Secrets we aren't telling them?

I can understand getting a copy of some result to take to another MD.......but the whole chart? Sorry, but the people who have asked me for the whole chart have been really difficult crazy pts and families.

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Specializes in Med/Surg.
the chart would have not existed if there were no patient and almost everything in the chart is about the patient. the patient owns the chart but i never said he could take it. he can only have a copy of it if he requires or he has the right to have any incorrect information in it corrected. the chart can be used as medical / nursing history by the patient which would be very useful if he transfers to another institution (specially if it is in another region).

If he doesn't take it with him, can only have copies of it, and has to go through a process to receive those...it's not his. It belongs to the facility. Yes, obviously the things in it are about the patient, but they're also about what the facility has done to care for the patient. It's the facility's property.

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Specializes in Trauma, ER, ICU, CCU, PACU, GI, Cardiology, OR.

Evidently, the patient has a right to view his chart, however they would have to go to medical records and sign a petition and get a copy of the chart. In addition, a nurse should NEVER allow a pt. read their chart while she's working on it. Lastly, in fact I would suggest that there should be a separate section for the Patient, where he ( or a family member) can enter their own notes ! This will allow the medical team to better comprehend what's going on in the patient's mind. This can also be useful for risk management, because it allows the doctor to document that the patient was kept fully informed at all times ! This way, the patient cannot change his story later on:cool:

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Specializes in Med/Surg, Academics.
Lastly, in fact I would suggest that there should be a separate section for the Patient, where he ( or a family member) can enter their own notes ! This will allow the medical team to better comprehend what's going on in the patient's mind. This can also be useful for risk management, because it allows the doctor to document that the patient was kept fully informed at all times ! This way, the patient cannot change his story later on:cool:

I would think this would open a whole can of worms that nurses and doctors would then have to spend an inordinate amount of time in defensive charting because the chart is also a legal document. Healthcare workers with charting responsibilities are taught to chart in a certain way...patients and families are not. What if a family member charted, "No one came to the room for a very long time after we pressed the call light!" The phrase "very long time" is subjective--could be five minutes; could be five hours. Who wants to have to deal with defensive charting at the end of every shift?

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Specializes in Trauma, ER, ICU, CCU, PACU, GI, Cardiology, OR.

dudette10,..Evidently, if I may add your reaction doesn't come as a surprise, for your information, it's been in practice for the past 3yrs. in 2 mayor facilities that I work for and the results couldn't be more favorable. Furthermore, I understand that change is always met with fear for most people, and as you stated "Open a can of worms" however, this is how most cures in medicine had been discovered by trial and error. Moreover, If you read my previous post once again, I'm not stating to hand over the chart to the patient, just to make them part of the solution. Lastly, your apprehension it's understandable it took comprehension and analysis of this issue to overcome and reach an agreement that the patient should be involved in their own welfare. In conclusion, I predict that you won't be the last to disagree, although I have high expectations that other professional nurses will read between the lines of my previous post and understand that we are all working for the benefit of our patients :redbeathe

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Facilities own the chart not the patient. If a patient wants a copy of the their chart we send them to the medical records to make a written request. They do have to pay a small fee and I believe the department legally has one month to hand it over but they seem to get it much sooner than that.

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The facility or institution owns the chart. The patient gains access to the chart by providing the institution with a written request. For copies of the chart, the patient makes a written request and pays any fee that the institution charges for administrative purposes. This info is stated in the privacy rights/HIPAA disclosure that institutions provide to patients when they enter into a healthcare relationship with patients.

Same where I work.

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it is the Patient's Chart so nomenclaturically speaking it is THEIR chart so they own it. This would vary on the country of practice though. Usually in public hospitals the patient and/or their S.O. can AT ANY TIME see their chart but in private hospitals, it requires a formal request to view the chart and even more measures if they want a copy of it.

I don't know anything about the subject, and have nothing informative to add. I can tell you that if I was a pt, and requested my chart, I would not expect to wait a week to have it mailed to me.

I am just posting to express my appreciation of the word "nomenclaturically". Is that really a word? If not, it should be.

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Specializes in Mostly: Occup Health; ER; Informatics.

I can't answer to various hospitals' policies, but in the U.S.A. there is quite clear Federal policy about who can access charts and when, and updating them. (45 C.F.R. 164.508, 164.524 and 164.526 and the easy-to-read http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/consumer_rights.pdf extracted here:)

"Providers and health insurers who are required to follow

this law must comply with your right to...

Ask to see and get a copy of your health records

You can ask to see and get a copy of your medical record and other health

information. You may not be able to get all of your information in a few

special cases. For example, if your doctor decides something in your file

might endanger you or someone else, the doctor may not have to give this

information to you.

In most cases, your copies must be given to you within 30 days, but

this can be extended for another 30 days if you are given a reason.

You may have to pay for the cost of copying and mailing if you request

copies and mailing.

Have corrections added to your health information

You can ask to change any wrong information in your file or add

information to your file if it is incomplete. For example, if you and your

hospital agree that your file has the wrong result for a test, the hospital

must change it. Even if the hospital believes the test result is correct,

you still have the right to have your disagreement noted in your file.

In most cases the file should be changed within 60 days, but the

hospital can take an extra 30 days if you are given a reason."

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the problem with waiting for 30 days, is that things "disappear"......and i think part of the problem in this discussion is semantics....yes the hard copy of the info, ie, the chart, is indeed the property of the facility/doctor...but the patient has at least the ethical and usually legal right to see and have copies made.

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Is it the patient or the hospital? Can a patient read his or her chart? Or a family member with the permission of the patient?

The chart belongs to the hospital and the patient is not allowed to read it.

Reading your own chart in HIPAA violation in the sense that ONLY people directly involved in a patient's care are allowed to view this chart, not even other nurses working in this unit are allowed to look at a patient's chart if they are not taking care of the patient. You may obtain copies of parts of your chart like lab, history and physical, diagnostic results am not sure about progress notes.

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