Factors to Consider When Releasing Patient Medical Records

Factors to Consider When Releasing Patient Medical Records Medical records release may be requested by medical record retrieval companies, and attorneys. Here are some factors to consider when releasing the records.

A patient’s health record contains highly sensitive personal and medical information that must be protected by healthcare providers to stay compliant with federal and state laws. The information in the medical record include patient history, examination results, test orders and results, diagnoses, presenting complaints, medications, details regarding consultations and referrals, patient conversation related notes, and so on. It is a matter of great concern therefore, when healthcare providers including hospitals and physicians are required to release medical records for purposes of medical record review.

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Personal injury, medical malpractice, workers’ compensation, and social security disability lawyers request the medical records of their clients for evaluation and case preparation.Typically, the request is made via medical record retrieval companies. It is important for medical record custodians to have a reliable system in place to enable the release of legible, complete, and properly organized medical records as and when the request is received from authorized entities. The person in a medical office responsible for gathering and producing the medical records must also stay compliant with the relevant regulations related to the release of confidential data. Healthcare providers are often hesitant to release patient records to attorneys, because they are concerned about breach of confidentiality.

So, what are the important factors providers should consider when releasing confidential patient information and also ensure HIPAA compliance?

•

Consider state regulations and HIPAA regulations when releasing confidential patient details. HIPAA requires that the records are released only with the written authorization from the patient.

•

The request for medical records can come from various entities as follows: o Directly from the patients, who may want the records for their own use. The request should be clearly signed by the patient. o From family members of the patient – in the case of a patient who is a minor, the provider can release the medical records to a custodial parent provided that the request is accompanied by an authorization signed by the custodial parent. If the record request is on behalf of a patient who is deceased or declared incompetent, the request must be accompanied by a medical authorization signed by the authorized executor of the patient’s estate or the patient’s appointed legal guardian. However, if the records are requested in connection with a healthcare liability claim filed under Chapter 74, they may be released if accompanied by a medical authorization signed by a parent, spouse or adult child of the incompetent/deceased person. o From an attorney, insurance company or some other entity. Such requests must be accompanied by a medical authorization signed by

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the patient. If the record request is in connection with a healthcare liability claim filed under Chapter 74 on behalf of a deceased patient or a patient who has been judicially determined to be incompetent, the record request must be accompanied by a medical authorization signed by a parent, spouse or adult child of the incompetent or deceased person. o The request may be made via a subpoena. If that is the case, the medical records can be released if the subpoenais accompanied by: ➢ A medical authorization signed by the patient. ➢ A court order signed by a judge, including administrative law judges. ➢ A qualified protective order, which indicates the parties involved in the lawsuit have agreed to an order and presented it to a judge for signature. This order must state that the PHI (protected health information) can be used only for the present proceeding, it mustn’t be shared with anyone else, and must be returned and destroyed at the close of the litigation. ➢ Documentation that confirms satisfaction of “notice to the patient” requirements. This documentation should indicate that the patient was served with a copy of the subpoena and that the reasonable time to object has expired.

It

is

important

that

the

accompanying

documentation establishes that the requesting party has made reasonable efforts to notify the patient (through mail or written notice) regarding the record request.

The documentation should also prove that no objections were filed.

•

If the patient chart contains information forwarded by a mental healthcare professional

(psychiatrists,

psychologists,

and

licensed

professional

counselors), the provider cannot re-disclose that information, even under subpoena.

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When releasing sensitive medical records to various requesting entities including medical record retrieval companies, healthcare providers must consider the above-mentioned factors. If in doubt regarding the proper release of medical records, it is best to obtain the counsel of an experienced attorney.

www.mosmedicalrecordreview.com

918-221-7791