Witholding informatiom the medical record.

[Mama Val, ASN, RN]

Question for any records people out there. ???

If you request your records from a hospital or clinic does the hospital have to provide everything that you asked for (checked off on the ROI, etc).

Can a healthcare facility choose to hold information and not give it to you. Even if the informnation came from another source but is is not a part of your chart now. I say no but am I wrong??? I am thinking that if they do hold stuff back they have to tell you what and why unless they are just trying to cover their own a$$.

Thanks

[Daytonite, BSN, RN]

I am in the middle of finishing up classes for an AA in health information management. A healthcare facility has to provide you with your medical records if you request them. If they are giving you a hard time remind them that under the HIPAA regulations they are required to provide them to you. However, they can ask you to pay for the copying and they may have you fill out a fancy, complicated request form. The main thing is that they need to have your signature for the release of your records to you as well as some identification on the release form of what you are specifically asking for. They may ask you for your social security number or your birthday just to verify they have the right chart. If you know your medical record number for their facility it helps them get the right record. (Save your patient ID bands in your medical file at home--your medical ID number is on them.) They are just covering themselves under HIPAA regulations. Patient confidentiality is a big, big, hot issue in medical records right now. You have a right to get a copy of everything that is in your chart and that includes nurses notes. To save on copying fees only ask for stuff that you really need. I have requested and gotten copies (for my own medical file at home) x-rays, doctor's consults, physical therapy records and OR reports.

What is this "other source" of a document in your chart that you are referring to? I can't think of what you are referring to. Are they telling you why they can't release it? If they failed to send you something you requested on your ROI I would get back in touch with them and find out what happened. They won't want to admit it, but sometimes parts of a chart get lost, or worse yet, the doctor didn't complete the chart. Still, you have the right to request that they obtain that information to the best of their ability. (They have problems getting some doctors to come in and complete their charts.)

[butterflynurse03, RN]

"other information" at some facilities might simply mean that the info was given them by the patient or another facility and therefore they can't pass it on. Many facilities will only give you information that is generated by them primarily. Hope that helps

[ceecel.dee, MSN, RN]

They are your records. Anything in your chart pertains to you and you should be allowed access to it.