Patient Record Access

April 1, 2007

When patients ask for a copy of their exam notes and/or their records when checking out, what is the best way to handle this? Do we need to photocopy them immediately? One of my doctors would rather type up a summary than give out copies of medical records.

Question: When patients ask for a copy of their exam notes and/or their records when checking out, what is the best way to handle this? Do we need to photocopy them immediately? One of my doctors would rather type up a summary than give out copies of medical records.

Answer: If this happens a lot, it’s another great reason to get an EMR that lets you print a summary report right from the record.

The answer also depends on what the patients want it for. Billing? Their own records?

If it’s the former, they might need the whole thing.

HIPAA simply states that patients need to be allowed access to their records. How you do so is somewhat discretionary. HIPAA allows you to require all patients to send you a written request for their records before you release them. And it states that you may offer patients a summary or their full records, according to their preference.

Otherwise, this is a work flow issue. Physicians who feel strongly about the summary approach should commit to sending a summary of the visit via e-mail to the patient on the next business day. If the patient won’t agree to do that, then just copy the most recent note and hand it over. Postponing such work only serves to make it more time-consuming.