Who owns Patient's Chart?

RhiaRN75, RN · Mar 11, 2010

I would guess the facility owns it as well. It's the facility that has the legal obligations. I believe a person should have access to their info, but it's the facility that has the legal burden to protect, store, and maintain that info.

On a side note, all of the facilities I have worked in were very reluctant to allow a pt (or someone they designate) the ability to read a current chart. In cases where pt's insisted, it was required to have the Doc or QC present. The rationale being that a current chart is a work in progress- incomplete and usually the only 'hard copy' available. What if, for example, the pt sees that their xyz was quite impressive and decides their PCP, wife, kid, cousin's fiance who is a nurse, etc. should see that! They take the hard copy out without letting anyone know. Or they decide that the H&P listing xyz by the doc is not something with which they agree so they remove it. In an ideal world we would notice the info is missing, but the reality is that if a pt has had a long hospital stay no one may notice that info from day one is missing. I've seen any number of people quite upset that we wouldn't just hand the chart over for them to peruse at leisure. The fact is though, we have the legal obligation to protect pt records.

GitanoRN, BSN, MSN, RN · Mar 11, 2010

hherrn, Evidently, you have something there when you stated that "Nomenclaturically" should be a word as a matter of fact this is what it means with a little change to the word itself, "Nomenclature" refers to either a list of names and/or terms, or to the system of principles, procedures and terms related to naming - which is the assigning of a word or phrase to a particular object or property. The principles of naming vary from the relatively informal conventions of everyday speech to the internationally-agreed principles, rules and recommendations that govern the formation and use of the specialist terms used in scientific and other disciplines. Therefore, this magnifies what has been discuss over and over and trust me, I feel you when one of you recently stated "in 30 days things could get misplaced". Moreover, this is exactly what has transpired with military men & women, they can't retrieve their medical records for whatever reason, and when they do it's usually missing important documents; or they are told that it's classify information, or they can't retrieve such. In addition, I have thousands of military patients that can't get their full benefits because their patient documentation has been loss or it never existed. Lastly, for all of you that are guarding this patient chart like a bible, keep in mind that one day you might be on the other side of the spectrum, and you would like to be included in your own recovery.

P.S. As I stated on my prior posting I'm not stating to hand over the chart to the patient, just to make them part of the solution of their mental & physical well being.:redbeathe

Otessa, BSN, RN · Mar 11, 2010

You may have to ask the HIM department.

Where I have worked the patient or family could not look at the chart unless they filled out proper paperwork.

otessa

morte, LPN, LVN · Mar 11, 2010

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.

i think you are twisting HIPAA six ways to sunday.....and are you trying to tell me that a patient isnt involved in their own care?????!!!!

GitanoRN, BSN, MSN, RN · Mar 12, 2010

& so it goes...

phrs and the hipaa privacy rule personal health records and the hipaa privacy rule

introduction

a personal health record (phr) is an emerging health information technology that individuals can use to engage in their own health care to improve the quality and efficiency of that care. in this rapidly developing market, there are several types of phrs available to individuals with varying functionalities. some phrs are offered by health care providers and health plans covered by the health insurance portability and accountability act of 1996 (hipaa) privacy rule, known as hipaa covered entities. the hipaa privacy rule applies to these phrs and protects the privacy of the information in them. alternatively, some phrs are not offered by hipaa covered entities, and, in these cases, it is the privacy policies of the phr vendor as well as any other applicable laws, which will govern how information in the phr is protected. this document describes how the privacy rule may apply to and supports the use of phrs.

what is a phr?: there is currently no universal definition of a phr, although several relatively similar definitions exist within the industry. in general, a phr is an electronic record of an individual's health information by which the individual controls access to the information and may have the ability to manage, track, and participate in his or her own health care. a phr should not be confused with an electronic health record (ehr). an ehr is held and maintained by a health care provider and may contain all the information that once existed in a patient's paper medical record, but in electronic form.

phrs universally focus on providing individuals with the ability to manage their health information and to control, to varying extents, who can access that health information. a phr has the potential to provide individuals with a way to create a longitudinal health history and may include common information such as medical diagnoses, medications, and test results. most phrs also provide individuals with the capability to control who can access the health information in the phr, and because phrs are electronic and generally accessible over the internet, individuals have the flexibility to view their health information at any time and from any computer at any location. the accessibility of health information in a phr may facilitate appropriate and improved treatment for conditions or emergencies that occur away from an individual's usual health care provider. additionally, the ability to access one's own health information in a phr may assist individuals in identifying potential errors or mistakes in their information. personal health records and the hipaa privacy rule 2 depending on the type of phr, individuals also may be able to input family histories and emergency contact information, to track and chart their own health information and the health information of their children or others whose care they manage, to schedule and receive reminders about upcoming appointments or procedures, to research medical conditions, to renew prescriptions, and to communicate directly with their health care providers through secure messaging systems. the phr also may function as a way for both individuals and health care providers to streamline the administrative processes involved in transferring patient records or for coordinating patient care. types of phrs : the phr market continues to evolve at a rapid pace, with new types of phrs continually emerging. for the purposes of this document, however, the universe of phrs can be broken down into two categories: those subject to the privacy rule and those that fall outside of its scope. phrs that are subject to the privacy rule are those that a covered health care provider or health plan offers. examples of phrs that fall outside the scope of the privacy rule are those offered by an employer (separate from the employer's group health plan) or those made available directly to an individual by a phr vendor that is not a hipaa covered entity. some stand-alone software packages or portable devices also may be available for use by individuals as phrs. however, while third parties may provide individuals with information to upload into these tools, since they are solely in the custody of the individual and are not offered by or connected to a third party, they will not be addressed in this document.

Zookeeper3 · Mar 12, 2010

In my facility, I will face termination if I pull up information on my own chart, even my childrens... without going through medical records and signing consent. Now a physician may write an order for me to read my chart, but a health care worker is present at all times then during my review. I'm never allowed to be left unattended with the chart.

RNMLIS · Mar 13, 2010

I recently requested my medical records from a a specialist that had been treating me...I was not happy with my treatment and there were billing issues when I requested the records...I called with no call back so I. I really expected to be asked to fill out a form. called again. The records were sent and were INCOMPLETE! Whoa!

Called back and records secretary said she had copied all. She offered to resend These records did .not arrive for a week and I went to get the records - they appear complete but not accurate The format seems strange as nothing was written all was transcribed from dictation.. Notes were in the form of a letter to my primary stating dx and blah blah

.All of the other record I have received from my MDs were hand written notes per visit.

So easy to change the notes in the format I received...you bet, in this case I am suspicious

On another note - They really should have asked me for some proof of idenity! HIPPA. I ept in mind the suggested 30 response time for records request. It took 21/2 weeks and I still wonder why sheets of my records were missing from the first delivery. go figure

morte, LPN, LVN · Mar 13, 2010

I recently requested my medical records from a a specialist that had been treating me...I was not happy with my treatment and there were billing issues when I requested the records...I called with no call back so I. I really expected to be asked to fill out a form. called again. The records were sent and were INCOMPLETE! Whoa!
Called back and records secretary said she had copied all. She offered to resend These records did .not arrive for a week and I went to get the records - they appear complete but not accurate The format seems strange as nothing was written all was transcribed from dictation.. Notes were in the form of a letter to my primary stating dx and blah blah
.All of the other record I have received from my MDs were hand written notes per visit.
So easy to change the notes in the format I received...you bet, in this case I am suspicious
On another note - They really should have asked me for some proof of idenity! HIPPA. I ept in mind the suggested 30 response time for records request. It took 21/2 weeks and I still wonder why sheets of my records were missing from the first delivery. go figure

you probably have hit on a problem with computor charting....in hospital you can go back (actually IT can) and determine if there have been any changes, but how do we know in the office setting? and the few that were missing, you have to wonder if they were being altered at the time and werent "ready for prime time" yet....

RNMLIS · Mar 13, 2010

EXACTLY! :mad: