You Can See Your Own Medical
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
"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
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
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:
|Your full name at time of treatment
|Date of birth
|Date of treatment
|Name and address of the person or facility to
which disclosure is to be made |
|The specific kind and amount of information to
be disclosed, such as laboratory results, X-rays or the doctor's notes on your chart
|The purpose of the request, for example,
"continuing care" or "insurance"
|Your signature and the date|
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:
|Person to notify in an emergency
|Name and phone numbers of personal physician,
dentist, optometrist and pharmacist |
|Important events and dates in your personal and
family medical histories |
|Important test results, such as X-rays and EKGs
|Dental information, such as dentures or bridges
|Copies of advance directives
|Organ donor authorization
|Health insurance information|
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.
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