Accommodating a Patient Request for Their Medical Record
By: Kim McGuire
CMS §482.13(d)(2) states that “the patient has the right to access their medical records, including current medical records, upon oral or written request in the form or format requested by the individual…
As healthcare leaders, we are so often focused on creating a productive and healthy care environment, as well as keeping up with changing regulations, the state of the world and normal day to day functions, that the functionality of our medical records release process may not be evaluated or tested.
In 2018, JAMA published an article in which compliance to federal and state regulations to medical record request processes were reviewed via a cross-sectional study of 83 US based hospitals. It was noted that there was noncompliance with producing medical records in the format requested by the patient and request processing times (please refer to your own organizational policies and state requirements). Additionally, there was discordance between information provided on medical records release authorization forms and that which was obtained directly from medical records departments regarding the medical records request processes (Lye, C., Foreman, H., Gao, R., JAMA, 2018). This not only creates confusion for the individual requesting medical records as well as staff preparing the requests.
Here is a quick check list to assist you in making sure that you are meeting CMS requirements:
- If the organization is electronic documentation based, is the medical record readily accessible and producible in electronic form?
- If the organization is electronic documentation based, is the medical record readily accessible and producible in a readable paper copy form? Many times, when electronic medical records are printed, although they are available, they may be hard to read. Let me give you an example that you may be able to relate to…. have you ever printed a large excel spreadsheet, and then attempted to read the second, third or even fourth page? Many times, it is unable to be deciphered. Is this what is happening with your medical records and would this meet the intent of the standard to produce a “readable hard copy form”? (CMS §482.13(d)(2), 2020).
- Does the capability of the organization to produce medical records request include radiology film and scans, laboratory reports, pathology slides, video and audio recordings and other forms of information regarding to the condition and/or care of the patient?
- Does the organization have a policy in place that defines what a reasonable timeframe is to produce the requested? Having this timeframe defined can lend to greater understanding and less frustration by patients who may have a different definition of “reasonable” than the organization defines. This also allows the medical record services, or whomever fulfills this request to understand the expectations of this request to be performed.
- Does the organization have a process that supports legitimate efforts of patients to gain access to their medical record or does it frustrate the efforts?
- Does the organizational process include methods to identify what and why documents were not included in the medical record request? Is the request form for medical records clear as to what records can be requested and does that mirror what information is available to individuals that call in or make verbal requests?
- Are the fees for medical record requests readily available and transparent to those requesting records? Are they accessible for the individuals requesting the records or does the fee frustrate the efforts of the individual to gain access to their medical records?
Requesting medical records remains a complicated and burdensome process for patients despite policy efforts and regulation to make medical records more readily available to patients, according to the study of the process. Study results revealed inconsistencies in information provided by medical records authorization forms and by medical records departments in select US hospitals, as well as potentially unaffordable costs and processing times that were not compliant with federal regulations (Lye, C., Foreman, H., Gao, R., JAMA, 2018).
Centers for Medicare and Medicaid Services, (2020). State Operations Manual, Appendix A – Survey Protocol, Regulations, and Interpretive Guidelines for Hospitals. Retrieved from www.cms.gov
Lye, C., Foreman, H., Gao, R., et al, JAMA Netw Open. 2018;1(6):
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