As caregivers, we are often overwhelmed by our loved one’s health information.
Different medical providers will ask about lab tests done elsewhere or the reason for new medications, etc. We can manage that information better if we have copies of the lab reports and doctors’ notes. It’s helpful to know how medical records work. It seems complicated but worth understanding.
The law is clear. We own the information and the provider who performed the service owns the document.
The provider can charge for providing the document. However, we are entitled to a copy of every medical document that has our name on it. All states have a protocol that may have minor differences, but basically work the same way. Each state’s Department of Insurance will have the protocols. Each provider should be able to explain your particular states laws and rules regarding the provision of medical information.
All health providers are required by Medicare to maintain records for a period of five to ten years, depending on the type of provider. As providers became overwhelmed with managing, retrieving and providing paper records, it became apparent that electronic records are preferrable for storage and access. In part, this is why all physicians enrolled in Medicare are required to implement electronic medical records.
Medicare wants all beneficiaries to be informed about their health and healthcare.
However, obtaining the information is where it gets complicated. All medical record software has to be compatible with Medicare defined standards. However, the software does not have to be compatible with other products.
For example, my physician may use Allscripts software and my hospital may use Epic. Allscripts may not be compatible with Epic although both are compatible with Medicare. What this means is that one provider may not be able to electronically access the lab results and notes from another healthcare provider. An easy transfer of electronic information was the promise if electronic records were implemented. It hasn’t been as successful as hoped.
As a result, we want to have a copy of lab results and visit notes each time we see a provider using a different documentation software. I’m not concerned if all my providers are part of one health system. But if I see someone outside that system, they may not have access to my loved one’s records.
Currently, we have electronic records that were built for many purposes, billing, auditing, tracking results to meet protocols. The result is a record that, if printed, could be 100 pages. We need to hone that request down to lab results, imaging results, admission and discharge documentation (even for an office visit). All the notes may not be completed when you leave. They can be mailed or picked up at a later date.
Do not be intimidated by office staff that asks why you want it.
You are legally entitled to it. You can put it in a folder (electronic or paper) for future use. Because you want it is answer enough. However, I suggest the best answer is “personal use”. You will have to sign a request form that also asks the reason. This is a state requirement to ensure the provider is meeting all applicable state laws for privacy.
We are not being unreasonable. It’s important we know these lab results and lab trends over time. It’s also important to read the notes. The notes will include a chief complaint (what brought you to the office), subjective information (what you tell the provider), objective information (what the provider observes), a treatment plan (what the provider considers next steps after putting the pieces together) and a diagnosis (working or final).
It’s helpful to have our own copies for reference and to share with our physicians.
As an example, I may see a pulmonologist for respiratory testing ordered by my family physician who receives the results. I also want my cardiologist to see the results. I can ask for a copy, paper or electronic, to give my cardiologist. Remember health information has to be secure, so no emailing records.
Frequently, if you request a copy at the front desk, someone will download and print your reports at no cost. Providers prefer patients to be informed. They want information to be readily available and are willing to make that happen. Many hospitals and clinics have patient portals where you can access, read, and download all your information as needed.
We need to take advantage of these processes. This information provides a foundation for our understanding and decision-making as we seek care among multiple providers.
written by Wanda Cantrell, RHIA, CCS, CCS-P, LPN
The column is based on Medicare guidance and reflects the views of the writer.
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