Re: What Should Be Included In Medical File?
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deadlock
The hospital has a more predictable set of records. They will have a form that tells you what you will receive. If you are looking for patient incident records or something similar that is not kept in the record, you have to be a little more savy in obtaining that information.
Please elaborate. How might one go about getting incident records? How might one go about getting ORIGINAL records, instead of the transcribed ones? Please share what you mean about being savy to get the information and how to.
I tried several times to get my records to no avail? When institutions/staff know they have done wrong, they cover their tracks immediately and the first step is denying accessing to records, limiting access to records, not providing all requested information, and even tweaking and changing records.
Re: What Should Be Included In Medical File?
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need2knowall
Please elaborate. How might one go about getting incident records? How might one go about getting ORIGINAL records, instead of the transcribed ones? Please share what you mean about being savy to get the information and how to.
I tried several times to get my records to no avail? When institutions/staff know they have done wrong, they cover their tracks immediately and the first step is denying accessing to records, limiting access to records, not providing all requested information, and even tweaking and changing records.
Original medical records must be kept by the Physician for 7 years, longer if the patient is under 18. You can obtain copies of your medical records by submitting a written request to the Physician/Facility. They have a reasonable amount of time to get the copies to you (in my state 30 days). There may be a fee.
If you feel there is something missing from your record, you have the right to set up an appointment to view the originals. For more information google: hipaa.org
It is illegal for healthcare providers to "cover their tracks" by altering or falsifying information in a medical record, and definately not worse the loss of their professional license.
Hope this info helps.
Re: What Should Be Included In Medical File?
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QUOTE=need2knowall;110194]Please elaborate. How might one go about getting incident records?
You can obtain them by subpeona. These are legal documents kept by risk management and belong to the hospital.
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How might one go about getting ORIGINAL records, instead of the transcribed ones?
You cannot obtain original documents. Again, these belong to the hospital.
You can ask to see your medical record in the Medical Record Dept.
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Please share what you mean about being savy to get the information and how to.
You can subpeona the legal department of the medical facility or corporation Duces Tecum to a Records Deposition, where your records are produced and you are permitted to to inspect and copy. Savy would be something..... like reviewing the records in the medical record department and upon your completion, serve the subpoena. The subpeona should specifically state producing all documents in their posession, custody or control, including incident reports or documents of sentinel events not kept in the medical record.
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I tried several times to get my records to no avail? When institutions/staff know they have done wrong, they cover their tracks immediately and the first step is denying accessing to records, limiting access to records, not providing all requested information, and even tweaking and changing records.
This is exactly why YOU DO NOT WRITE A LETTER TO THE HOSPITAL REQUESTING A COPY OF YOUR MEDICAL RECORDS. OR THE DOCTOR'S OFFICE OR ANY OTHER PROVIDER.
Go to the facility and request to see your medical record. Make notes about what you see written. Then ask for a copy to be made of those specific pages that you want. Making contact with them prior to your intention to look at the record will sabotage a potential case you may have.
I suggest if you are intending to bring a claim against a provider, see a medical malpractice attorney.
Re: What Should Be Included In Medical File?
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lealea1005
Original medical records must be kept by the Physician for 7 years, longer if the patient is under 18. You can obtain copies of your medical records by submitting a written request to the Physician/Facility. They have a reasonable amount of time to get the copies to you (in my state 30 days). There may be a fee.
If you feel there is something missing from your record, you have the right to set up an appointment to view the originals. For more information google: hipaa.org
It is illegal for healthcare providers to "cover their tracks" by altering or falsifying information in a medical record, and definately not worse the loss of their professional license.
Hope this info helps.
Thanks but I have done EVERYTHING you said already. I was armed with a printout of the full hippa [act], which I went so far as to read the entire document beforehand, every page every word to get a feel for all the guidelines. When I whipped the report out that got me booted out of the records office. As far as your last comments...many things are illegal and yet people commit crimes every day. Case in point, many lose their license for such and lesser offenses daily. What's most interesting is that I originally wanted the records for more benign reasons than they could have imagined. However, their delaying and denying made me suspicious and where there is smoke there is fire.
I did not intend to start this thread. I was asking someone esle about a tactic they specifically alluded to in a different thread, or so I thought. I am new here so I will probably make a few errors; I apologize in advance. :)
Re: What Should Be Included In Medical File?
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deadlock
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This is exactly why YOU DO NOT WRITE A LETTER TO THE HOSPITAL REQUESTING A COPY OF YOUR MEDICAL RECORDS. OR THE DOCTOR'S OFFICE OR ANY OTHER PROVIDER.
Go to the facility and request to see your medical record. Make notes about what you see written. Then ask for a copy to be made of those specific pages that you want. Making contact with them prior to your intention to look at the record will sabotage a potential case you may have.
I suggest if you are intending to bring a claim against a provider, see a medical malpractice attorney.
Umm, I tried. I was told it couldn't be done, only by appointment. What does one say to the only by appointment and only in writing retort? What does one say when essentially blank pages called "transcribed" to be exact "transcribed from recordings" is stated all to exist? (I saw the handwritten chart several times, so I knew I was being lied to.) I whipped out the printed act in response to all of these and asked to be shown where in the law; I got booted out of the office. Why does the hospital own my record? I remember reading something like that in HIPPA document but I vaguely remember that I have a right to request access and/or copies of my original medical record(s). I want to say that I remember the word original but it has been months and the woman did tell me that she doesn't have to provide me my original record; well doesn't that imply that they can and do change records. I only consider the original my true record and that is the one I want. :wallbang:
Seriously, you have been great to address my issues. It was kind of you and I do appreciate your explanations and your time.
Your entire reply was helpful; thank you very much.
Re: What Should Be Included In Medical File?
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rmet4nzkx
As Lealea correctly informed you, there may be a charge, this is something they will inform you of when you order your records, if there are a lot of records, you and or an agent may do an on site review of the records and order specific copies of the originals. Please understand that a facility may only provide you with copies of their original records and not that of other provider's. records that may be a part of your file, that is where the on site review may be necessary. In other cases and in the case of psychological records, the provider may only be required to provide a report in lieu of the original records, or to send the records to another provider who will supervise your review.
Most facilities have member services or ombudsman to help you when you encounter difficulity. I hope this helps.
I don't have any psychiatric records or mental records of any kind nor drug records as I have never experienced any of these ailments. The facility specific to me had everything scanned into the computer immediately and as it should be in every hospital the written chart is transferred to each dept with the patient. So all of the records where together before I left, plus a nurse informed me of exactly that when I asked about the records; pluse she said that the full chart is taken to records dept immediately and would be scanned & completed within an hour of a patient service completion. Of course, medical records denied it because something happened that they don't want me to know about.
Re: What Should Be Included In Medical File?
Thanks all for the responses. I think the end result is that facilities and doctors CAN be as unscrupulous as they choose.
Re: What Should Be Included In Medical File?
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need2knowall
Thanks all for the responses. I think the end result is that facilities and doctors CAN be as unscrupulous as they choose.
needtoknowall, I understand you're upset and frustrated. It's unfair to make generalizations about the character of a whole profession. As with any profession, there are always the proverbial bad apples. I've been a nurse almost 24 years. I can honestly say there have been very few providers I've met over the years that I would steer clear of because of questionable practices.
Hope things work out for you. Have a good day.:)