Contents Legal system Malpractice Avoiding malpractice Medical record Introduction Proper documentation Subjective vs objective Legal considerations Managing records Record storage Releasing records Viewing records Withholding records Selling records FAQs Patients' rights QUIZ

Releasing medical records to the patient or family Although the medical record belongs to the physician or organization that created it, the information in the record belongs to the patient in the sense that the patient has the right to access that information (except in certain situations as noted below) or to deliver it to a third party. Whenever a patient requests a record, written permission should be signed (by the parent, if the patient is a minor), dated and placed in the chart. Releasing medical records to a third party A physician must always have the patient's original, signed, dated permission before releasing copies of records to a third party (e.g., insurance agents, other physicians, employers, attorneys, etc.). Some physicians have patients sign a blanket release at the first visit which allows release of medical information, without further paperwork, to consulting physicians, laboratories, emergency rooms and other health care providers. One exception to the need for written permission is if the record is the subject of a court-ordered search warrant. If the record is copied, it should be so noted in a dated entry in the chart. Physicians may charge a fee for copying a medical record. The fee should reflect the cost of actually copying the record and, in Connecticut, should not exceed $ 0.65 per page plus first class postage for hospitals and $ 0.45 per page plus postage for physicians' offices. Special situations: Viewing the medical record If a patient, family member or third party requests to view the original record (after presenting a recent, original, dated, signed permission slip), a staff member should be present to maintain the integrity of the record, prevent additions, and to answer questions. After review, a note should be placed in the record, along with the permission slip, stating the date, time, reason for review, and the name of the staff member present. Hospitalized patients are not generally allowed to view their records, because they are considered incomplete until operative reports, lab reports and discharge summaries are signed and placed in the chart. There may be occasions, however, when, to defuse a situation, it may be prudent to allow a patient to review his or her record. In these cases, a staff member should be present as during any other review of the original record.