Your health record represents a valuable timestamp of the care you received. In fact, the saying, “If it wasn’t documented, it wasn’t done,” is a common phrase in the medical world.
Whether you’re looking to provide proof that you received proper care, trying to justify why you deserve a prior authorization from your insurance plan or another reason, the medical record is your only evidence.
The Privacy Rule of the federal Health Insurance Portability and Accountability Act (HIPAA) entitles all patients to have access to their medical records, and that during the transmission, your privacy is protected. Even so, you can encounter pushback.
Learn more about how to access your medical records, why you might need them and your rights in receiving those records.
How to Request Your Medical Records
Before you request medical records, remember that you have a right to receive your records within 30 days of your request. You should not feel that you are inconveniencing the facility by asking.
There are several ways to access or request your records:
1. Check your patient portal
You can start by checking your patient portal, which contains all medical records for patients with active accounts, and they can be viewed or securely shared between patients and medical providers.
2. Visit the facility’s website
The website may have instructions on how to access your records or have a form for you to complete.
Both of these methods may still require that you request the records via fax or in writing, but the facility should guide you on how to complete that process. If your concerns are not addressed, you can contact the Department of Health and Human Services for information on how to report the facility and file a complaint.
HIPAA also gives you the right to request an amendment if you notice an error in a medical record, such as an incorrect medication or allergy. In cases like these, the clinician who made the original documentation often makes the change.
3. Call the facility
If you don’t have a patient portal and aren’t sure where to start, call the facility where you are requesting records. They can explain their protocol for record transmission to ensure you get the records in a timely manner and with your privacy protected.
In clinic settings, the receptionist can often assist with these requests. In the hospital, if you reach the operator, ask for the health information department to be directed to the right person.
4. Visit the facility in person
Patients can visit medical facilities during business hours to complete the authorization forms for medical record release. If you haven’t been able to reach someone by phone or if you are in the area, this is a viable option.
[Read: What Is an Ambulatory Surgery Center, ASC?]
What Information Is in Your Medical Records?
Medical record formats differ depending on the care setting, where you received care and the electronic health record system used. However, some form of record will accompany all medical interactions, including:
— Inpatient hospital admission
— Elective surgery
— Physical therapy or occupational therapy evaluation
— Clinic visit
— Vaccination appointment
— Blood donation
— Imaging appointment
Depending on the care setting, each medical record contains multiple sections with key documents. These may include:
— The initial history and physical examination
— Consultation reports from specialists, such as cardiologists or neurologists
— Operative reports
— Significant test results, such as echocardiograms or MRIs
— Current medication list
— Discharge summary
Managing extensive medical records
Inpatient medical records, in particular, are filled with redundancies. Each day of an inpatient stay will have new daily progress notes, but will also repeat previous information, like past vital signs, most recent labs, reason for admission and a list of medications.
Unfortunately, there isn’t a way to have the repeated information removed upon your records request. If you do receive hundreds or thousands of pages, here are some tips to sort through the information:
— Search for relevant information. If you receive the information in a digital file format, try searching for keywords by pressing “Ctrl + F” on your keyboard to search through the PDF document. However, not all documents accommodate this search function, particularly if they have been manually faxed or are in a JPEG or IMG format.
— Scan for key elements of the record. Some of the most useful health information will be under headers like H&P (history and physical), admission note, operative note, daily progress note and discharge note.
— Create a table of contents for yourself to reference later. If the document doesn’t have one already, scroll through and make a note of where the information is located. For example, page 6 has the admission note, and page 37 has the operative note.
[READ: Questions You Need to Ask Before You Leave the Hospital.]
Why Would You Need Access to Your Medical Records?
You have a right to have access to your medical records no matter the reason.
Some circumstances where requesting records are particularly important include:
— If you are changing medical providers
— Getting a second opinion. For example, if you want to see a second orthopedic surgeon to see if they also recommend a knee replacement, you will want to send them your initial imaging and surgical consult.
— If you want to submit them for an insurance claim, or for an insurance appeal
— If you believe you have a legal case for medical malpractice, or if you feel you did not receive adequate care during your stay
— If you need proof of care, such as for a disability claim, a hospitalization for a work or school excuse or a vaccination record for traveling
[READ: Where to Turn for a Safe and Efficient Hospital Transfer]
What You Don’t Get to See
While it is your right to access your medical records, there are a few exceptions, including:
— Psychotherapy notes. According to the HHS, psychotherapy notes receive special protections. This includes any notes related to the contents of a conversation held in a therapy session. Patients are not permitted access to psychotherapy notes — as they’re typically not required or useful for treatment, payment or operations purposes — and health providers can also withhold information if they think it could endanger the physical safety of the patient or another person. You can still request the notes, but the therapist can choose which records, if any, to release to you.
— Records of minors. Depending on your state, parents may or may not have access to some parts of their child’s medical records. For example, in Washington state, parents have limited access to medical records of minors once the child turns 13. Additionally, parents may not receive access to psychotherapy notes for their child.
— Records of a spouse. Unless they have direct, signed authorization from the patient, spouses will not be given access to his or her medical records.
If you are the caregiver or loved one requesting records on someone’s behalf, you can do so with written permission or if you have power of attorney. If you need to clarify your right to receive someone else’s records, call the health information department or receptionist at the facility you are requesting from.
Potential Roadblocks to Accessing Medical Records
You may encounter some challenges in accessing your medical records.
These may include:
— Not having a patient portal, so you can’t access records on your own
— Difficulty locating the authorization form, completing and mailing or faxing the form
— Delays in the facility receiving the form via mail or fax
If you feel the facility is purposefully withholding records, make sure you make your request in writing with the date clearly stated on the request. You’ll also want to keep a copy of the original request. That way, you have a paper trail if you need to report anything, or in the worst case scenario, if you need to seek legal action.
The facility has closed down
Each state has its own regulations on medical record retention requirements, dictating how many years the medical records need to be stored after the practice has closed.
To track down your records, try:
— Calling the medical office or visiting their website, in case they still have interim services
— Contacting the local hospital the practice was affiliated with. Many hospitals and smaller practices share medical records.
— Getting in touch with your state health department or state medical association for additional assistance
Even if the practice has shut down, you can still file a complaint with the HHS if you don’t receive your medical records.
The facility charges a fee to request records
Facilities can charge a “reasonable” fee to send you medical records to cover postage or faxing, if applicable. However, HHS does not allow a facility to charge you for searching for, retrieving or digitally sending your medical records. The facility also can’t charge you for outstanding medical bills or debt accompanying medical records when you request a copy of them.
Contact HHS if you believe you are being charged an exorbitant fee for your medical records.
Protecting Your Privacy During Record Transfer
The same laws that grant you rights to your medical records also mandate the privacy of your records during that transfer.
For example, at HonorHealth, a nonprofit hospital system in Arizona, all records are encrypted, regardless of whether they are emailed or copied to a CD.
If you need records sent from one facility to an outside provider, “patient medical records are only faxed after verification of their fax number,” Brad Peterson, the network senior director and health information manager at HonorHealth in Scottsdale, Arizona.
If you’re using a patient portal, most require two-factor authentication.
There is a federal initiative to implement a national framework for the exchange of health records to reduce the need for patients to manually request copies.
“The Department of Health and Human Services, through the Office of the National Coordinator for Health Information Technology, have set up the Trusted Exchange Framework and Common Agreement (TEFCA) to allow health care organizations to share information in a secure manner. Specifically, groups of health systems join Qualified Health Information Networks (QHINs) such as Epic or eHealth Exchange, to facilitate this secure exchange,” says Dr. Jim Whitfill, the senior vice president and chief transformation officer at HonorHealth in Scottsdale, Arizona.
As of December 2023, TEFCA became operational, with limited back-end document exchange between participating networks. The project is rolling out in stages and ideally, by the end of 2025, patients will hopefully be able to access their health information at once for all participating platforms.
The Bottom Line
You have a right to access your medical records within 30 days of your request. Your medical records may be hundreds or thousands of pages long, so be prepared that it may take time to go through them if you are seeking specific information.
If you are requesting records be sent to another provider office, your privacy should be protected. You may request your records by visiting the facility in person, contacting them by phone, visiting their website or visiting your patient portal.
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How to Get Access to Your Hospital Records originally appeared on usnews.com
