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  1. #1

    Default What Should Be Included In Medical File

    I had a new question that relates to my previous, and was not sure if I just added it to the first one, if it would have been read.

    I received today the records from the doctor, but still feel there is material missing. I'm not asking if other doctors notes should be in there, because we discussed this already. I'm talking about material just from this doctor.

    All I received was the office visit report for each month I was seen. Should there be other things like reports from labs, and should the doctor have included the informed consent?

    Its been about 4 years since the first visit, and dont remember signing an informed consent. And would like to know if this should have been included.


    Thanks again,
    NYC

    PS: Again, I apologize if this should have been posted in first topic. But felt because it was a new question, if I asked in old topic it would not be read.

  2. #2
    Join Date
    Mar 2005
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    Michigan
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    Default Re: What Should Be Included In Medical File?

    If you didn't sign an informed consent, why would you expect one to be in your file?

  3. #3

    Question Re: What Should Be Included In Medical File?

    Hello,

    You raise a good point, however I said because it had been about 5 years since my first visit...I dont remember if I did sign one or not. Thats why I'm asking if I did in fact sign it, should I also have received a copy of it.

    As well, what else should I have received with the copies? I thought asking for the complete medical record, would mean to copy everything. But does this mean, I have to name every single type of material?


    Thanks again,


  4. #4
    Join Date
    Jul 2006
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    Ohio
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    Default Re: What Should Be Included In Medical File?

    Quote Quoting myfind2006
    View Post
    Hello,

    You raise a good point, however I said because it had been about 5 years since my first visit...I dont remember if I did sign one or not. Thats why I'm asking if I did in fact sign it, should I also have received a copy of it.

    As well, what else should I have received with the copies? I thought asking for the complete medical record, would mean to copy everything. But does this mean, I have to name every single type of material?


    Thanks again,

    You must sign a release of information. That gives the medical facility the right to copy your records and send them to anyone you specifically identify on your authorization to release that information, including YOU.

    If you are trying to obtain records about an inpatient stay, the doctor does not have those records. They are all maintained by the facility. So you go to the hospital and fill out a request and sign the authorization. You must request an authorization to release that information to yourself. And 5 years ago doesn't meet the requirement. It has to be current. Any time you want records you have to sign a new request.

    When you ask this forum about what records you can anticipate as your "complete record", no one can guess because we don't have any idea what type of visits, your medical problems, how many consults were made and the entire diagnostic workup that might be included in your situation.

    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.

    Your posting in Med Mal so if you are thinking about a malpractice claim you need to be aware of the SOL in your state.

  5. #5

    Default Re: What Should Be Included In Medical File

    Hello,

    Deadlock...Please understand I'm not trying to attack your post. I do appreciate your taking the time out to help.

    What I was trying to say was I have been seeing this doctor for about 5 years and because it had been so long ago since my first visit, I don't remember if a informed consent was signed. I was (not) saying I signed a release form 5 years ago. Meaning, on my very first office visit in 2001 the doctor (might have) wanted me to sign a informed consent before we start the treatment plan.

    As for the records and stating type of visits, medical problem and etc...I don't understand why this would matter at all. If I had a breathing problem or cancer, for the most part, they both would have the basic kind of papers, no? I was asking for a 'off the top' of your head, what are some of the type of files, that any medical record would consist of. I've been to a lot of doctors and had my own idea's on what kind of papers should be in a medical record but wanted to see if anyone else, might know of one I didn't think of. Most records regardless of problem, would have...the diagnostic workup paper you fill out on first visit, any lab work reports, film reports for having any x-rays/MRI's, and the office reports that are written on each visit. Aside from those, I can't think of any others. I understand not everyone would have film reports.

    Lastly...the record would be coming from the doctor at his office.


    Again, thanks for all the efforts and time,
    JS

  6. #6
    Join Date
    Jul 2006
    Location
    Ohio
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    Default Re: What Should Be Included In Medical File

    Quote Quoting myfind2006
    View Post
    Hello,

    Deadlock...Please understand I'm not trying to attack your post. I do appreciate your taking the time out to help.

    What I was trying to say was I have been seeing this doctor for about 5 years and because it had been so long ago since my first visit, I don't remember if a informed consent was signed. I was (not) saying I signed a release form 5 years ago. Meaning, on my very first office visit in 2001 the doctor (might have) wanted me to sign a informed consent before we start the treatment plan.

    As for the records and stating type of visits, medical problem and etc...I don't understand why this would matter at all. If I had a breathing problem or cancer, for the most part, they both would have the basic kind of papers, no? I was asking for a 'off the top' of your head, what are some of the type of files, that any medical record would consist of. I've been to a lot of doctors and had my own idea's on what kind of papers should be in a medical record but wanted to see if anyone else, might know of one I didn't think of. Most records regardless of problem, would have...the diagnostic workup paper you fill out on first visit, any lab work reports, film reports for having any x-rays/MRI's, and the office reports that are written on each visit. Aside from those, I can't think of any others. I understand not everyone would have film reports.

    Lastly...the record would be coming from the doctor at his office.


    Again, thanks for all the efforts and time,
    JS
    Not at all.

    Your terms are confusing me a little so that is why I have used "release" or "authorization".

    I simply don't know what you are trying to get. And it is not necessary for me or the forum to know.

    But if you are vague with the doctor, or the record department of his office then you will receive vague answers/responses.

    I suggest you ask for what you want, ie my treatment plan, my signiture on the treatment plan, my radiology report, my authorization to receive chemo, whatever.

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