You Can See Your Own Medical Records
J. Greene


      Terry Fotre was visiting an acquaintance who was a patient at a hospital. They got to talking about her condition and wanted to look at her medical chart.
      "She asked the nurse to see her record, and the nurse said, 'No, you can't see it. That's against hospital policy,' " Fotre says.
      The nurse obviously didn't know who Fotre was, or she might have double-checked on that policy. Fotre is not only a physician, but the chairman of the California Medical Association's information technology committee, and is intimately familiar with the state law that gives residents the right to see their own medical records.
      "I called the hospital administrator the next day and they said the nurse was wrong, and she could have seen her chart," Fotre says. "There are some misguided people out there who don't know that patients have this right."
       To avoid being the victim of a misinformed medical professional, it pays to know your rights. In fact, some consumer advocates argue that it's a good idea for patients under treatment to take a look-see at their own medical charts to make sure the doctor has written down everything accurately. Such a move can come in particularly handy if you're ever in a dispute with your health plan over the necessity of some medical care, notes Dr. Vincent Riccardi, founder of American Medical Consumers.
      Riccardi says medical notes can be inaccurate or incomplete, leading to confusion and allowing an insurer to avoid responsibility.
      "Let's say you report to your doctor a couple of times that you're having severe headaches, and a few months later ask for an MRI," Riccardi suggests. "If your doctor never wrote down there was a long-standing concern about headaches, the insurer's utilization review committee is going to look at those records and turn down the MRI."
      Another thing to look for in your records is any improper language that could color how another medical professional sees you. For instance, your chart shouldn't include unnecessary or biased comments about you, notes "Health Care Choices for Today's Consumer," a guidebook put out by Families USA. "Health-care providers should record facts about a patient (for example, "speech slurred, eyes bloodshot") rather than conclusions that may not be true ("patient is an alcoholic"), the book notes.
      It may not be possible to collect every bit of medical information that's in writing about you, Fotre says, since it's not all in one place. Each doctor, hospital or other medical provider keeps its own records, so it's not like a credit report where the information is shared and kept in a single place. Still, if you've had a major, complex or expensive course of treatment or had a conflict with a provider or insurer, it's a good idea to ask for a copy of your record. It would also be interesting to know what kind of information you're releasing to others when you sign a consent form allowing disclosure of your records to insurance companies or employers.
      So how do you get a copy of your records? Most states give patients the right to their medical information. But some states' laws don't address the issue at all, and some may place restrictions on the information you can get. In many cases, psychiatric information about you may be difficult to get; Fotre said psychiatrists tend to be concerned that a patient who is delusional could misinterpret the doctor's notes and become psychotic.
      Technically, the documents belong to whomever made them, but in most cases the information about you belongs to you. To find out how your state handles this issue, contact the state Department of Health; it's also likely your state's medical society, which represents physicians, would be aware of patients' rights to information.
      Even in states where the law is restrictive or unclear, many medical providers will provide your records to you anyway, according to the American Health Information Management Association, whose members are the keepers of the nation's health records.
      To get them, ask your doctor's staff, hospital records clerk or other appropriate person for a patient authorization form that allows the release of information. You can also write a letter, being sure to include the following information. This also works if you are authorizing the information to be sent to another person, such as a new doctor:

bulletYour full name at time of treatment
bulletDate of birth
bulletDate of treatment
bulletName and address of the person or facility to which disclosure is to be made
bulletThe specific kind and amount of information to be disclosed, such as laboratory results, X-rays or the doctor's notes on your chart
bulletThe purpose of the request, for example, "continuing care" or "insurance"
bulletYour signature and the date

      If you've been in the hospital, Riccardi suggests you be sure to get certain documents afterwards. If you didn't have surgery, just ask for the discharge summary, typed admission history and the front sheet that contains the codes for your diagnosis and the type of service the doctor is charging for. Also enlightening can be the progress notes written by doctors, and nurses' notes, which often have more detailed information because the nurses are around more often. If you've had surgery, you can ask for the operative report, anesthesiology record, dictated operative notes, pathology reports (if any tissues were sent to the lab) and recovery room notes.
      You may be charged a reasonable fee for the copies. If you haven't gotten the records after about two weeks, bug them again.
      It's a good idea to keep all this and the following additional information in one place at home, recommends the AHIMA, and make sure other family members know where it is:

bulletPersonal identification
bulletPerson to notify in an emergency
bulletName and phone numbers of personal physician, dentist, optometrist and pharmacist
bulletCurrent medications
bulletImportant events and dates in your personal and family medical histories
bulletImportant test results, such as X-rays and EKGs
bulletEyeglass prescription
bulletDental information, such as dentures or bridges
bulletCopies of advance directives
bulletOrgan donor authorization
bulletHealth insurance information

      If you live in California, there's a nifty online resource available from the California Medical Association, which has on its Web site detailed information about your rights to medical records in that state. It also provides various medical legal forms anyone can use for health-related situations, such as parental consent for medical treatment and a document that will allow your babysitter or a teacher to authorize medical treatment in an emergency.
      Another good online site belongs to AHIMA, which also offers a number of health-related legal forms and advice.


Our Rights Return
Our Rights Return