Patient Keeping Charts

November 1, 2008

We recently had a patient in a treatment room, awaiting a physician (who was late from a surgery). The patient took her chart with her, and left the office without being seen by the physician. When we discovered that she’d left and the chart was missing, we called the patient. She admitted she had taken the chart, claiming it is “her” medical record. We explained that the chart is in fact the doctor’s property, but we offered to make copies for her. We also asked if she wanted to reschedule her appointment. She said “not at this time.” Is there a form letter we can use to notify a patient that medical records belong to the doctor? What should we do to offset any liability?

Question: We recently had a patient in a treatment room, awaiting a physician (who was late from a surgery). The patient took her chart with her, and left the office without being seen by the physician. When we discovered that she’d left and the chart was missing, we called the patient. She admitted she had taken the chart, claiming it is “her” medical record. We explained that the chart is in fact the doctor’s property, but we offered to make copies for her. We also asked if she wanted to reschedule her appointment. She said “not at this time.” Is there a form letter we can use to notify a patient that medical records belong to the doctor? What should we do to offset any liability?

Answer: I think I’d start by calling the patient back and just explaining why you need the record back (liability, etc.). I’d also sure apologize for keeping her waiting so long that she decided not only to leave, but apparently to leave the practice.

Having her doctor make the call might make sense.

If she understood more fully, she might simply comply. Make it clear that this is isn’t about forcing her to continue as your patient, although you sure hope she will. It’s about liability, continuity of care, and so on.

If she doesn’t reply to this, I’m not sure a letter will work either. I’d think your next step is to call the risk management department of your liability carrier to ask what they suggest you do to protect yourself. They’d have to defend you should it come to that, so they should be the ones guiding you.