New standard protects patient access to records
By Patrice Spath, ART
Brown-Spath Associates
Forest Grove, OR
On Aug. 2, 1999, all Medicare and Medicaid participating hospitals were expected to implement several new or strengthened patients’ rights standards. One is a standard requiring hospitals to give patients access to the information contained in their clinical records within a reasonable time frame.
According to the Conditions of Participation (CoPs), the hospital "must not frustrate the legitimate efforts of individuals to gain access to their own medical records and must actively seek to meet these requests as quickly as its record-keeping system permits." The standard is based on the belief that a patient can only take an active and meaningful role in health care decision-making if he or she is allowed to know what is happening.
To ensure that the intent of this standard is met, all hospitals must have a well-defined policy and efficient record release process. In addition, hospitals should periodically monitor record release activities to verify that records are being made available to patients within the time frame defined by the organization.
Although health records are the property of the health care facility, patients have a right to examine their own records and to copy information contained in them. If they do not understand the information in the record, they have a right to an explanation from their physician or another qualified health care professional. Patients may be denied access to the record if the physician reasonably believes that the patient or others (other than a health care provider) will suffer substantial physical, mental, emotional, or legal harm because of information contained in the record. However, even in these situations, the patient should be allowed to review the portions of the record that do not meet these criteria. Such denials should be rare, and the onus is on the physician and health care facility to justify denial of access.
The hospital should have a clearly defined policy and procedure describing the circumstances in which patients may review their records and how this review process takes place. The issues that should be addressed in these policies/procedures include:
• Signed request process.
Some hospitals have developed a "Request for Access" form that is completed by the patient, or, in the case of patient incompetency, by his or her representative (as allowed under state law). Many hospitals use their standard release of information form for this purpose.
• Physician notification.
Generally, hospitals notify the patient’s attending physician that a record is being released to the patient. If the record contains potentially harmful information, this notification should occur before the release occurs. The physician may determine whether such release is in the best interest of the patient and may request that certain portions of the record be withheld. If access to a portion or all of the record is denied, it’s important to have the physician document the reason for disapproval in the patient’s record or on a separate record access request form. Be sure physicians understand the bases on which access to portions of a record can be denied. The Health Care Financing Administra tion (HCFA) will view groundless denials as a violation of the Patients’ Rights standards of the CoP. Denial of patients’ access to their own records also may violate state regulations.
• Process for interacting with patients.
When a patient requests access to his or her record, it’s important to explain the process followed by the hospital. If the health information management (HIM) department requires that the patient make an appointment to review the record, instructions on how to go about making an appointment should be shared.
• Record preparation.
Prior to releasing a record, it should be reviewed, and any material not specifically requested and approved for release should be removed. The hospital’s policies and procedures should state clearly what material will routinely be removed from records prior to sharing the record with the patient.
• Record review supervision.
At no time should a patient be allowed to review the original record without direct supervision by a facility employee or a physician. If the patient needs an explanation of information in the record, a credentialed health care professional should be available to assist. Any interpretation questions the patient may have should be directed to the attending physician, who should answer these questions to prevent misunderstandings.
• Photocopy charges.
Hospitals may charge a reasonable amount for record photocopies requested by the patient. However, HCFA emphasized that pricing must not create a barrier to the individual receiving his or her medical records. Some states have statutes that limit the amount that patients can be charged for record photocopies. HCFA will view charging excessive fees for copies of a patient’s medical record as an attempt to frustrate the legitimate efforts of individuals to gain access to their own medical records.
• Access time frames.
The CoP does not specify an exact time frame in which patients should be allowed access to records. HCFA chose to use the term "reasonable" to describe how quickly hospitals should respond to record access requests. Hospitals should, in their own internal policies, establish a definition for the term "reasonable" so they can measure performance in this area. Be sure to check applicable regulations in your state, as they may specify a time frame. Once you’ve defined a time frame, it’s important to monitor compliance regularly to ensure actual performance meets your facility’s expectations.
• The department or disciplines responsible for implementing the process.
Generally, the HIM department is responsible for sharing closed records with patients after they’ve been discharged from the facility. How ever, in situations where the patient is still in the hospital, it’s important to define who will respond to record review requests. Whoever owns the responsibility of releasing records to patients should be familiar with the relevant policies and procedures and understand what to do if the physician denies access to parts or all of the record.
Consider incorporating statements similar to those found in the accompanying figure into the Patients’ Rights notices that are provided to all patients. (See Patients’ Rights Statement, p. 174.)
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