Internal Medicine Coding Alert

Don’t get into legal hassles by postponing patient demands for records.

You might have encountered patient requests to access their medical records time and again. When a patient requests access to her medical records, practices should use this as an opportunity to foster trust and openness with the patient.

If you do it correctly, your response to a patient’s records request can kill two birds with a single stone:

• A patient has every legal right to her medical records, and if you don’t provide access, the law will take notice; and
• Failure to respond to patient record requests will almost certainly erode patient trust.

Be compliant, and remain trustworthy to your patients, by following this expert advice on responding to patient requests for medical records access.

Give Multiple Access Points for Patients

According to Maria V. Ciletti, RN, who works as a medical administrator in Niles, Ohio, and is also a member of the American Medical Writers Association, these are the best choices for the practice when a patient submits a records request:

1. Send medical records to the patient through an online patient portal, if your practice offers this option.
2. Copy the patient’s record, and let her come into the office and review it when staff members are available to answer questions, and make sure you have the patient sign that they have picked up their records
3. Copy the requested records and hand-deliver or mail them to the patient.

Consider Risks before Offering These Digital Options

In addition to the above access points, you might also allow patients access to their record via the following means, according to Jim Sheldon-Dean, principal and director of compliance services for Lewis Creek Systems, LLC, in Charlotte, Vt.:

Email: If a patient wants his records sent via a standard email attachment, you can oblige. To make sure the patient understands that this isn’t a secure method to send medical records, document that they have requested the unsecured transmission and that you have explained that “there are risks of exposure of the information using plain e-mail,” Sheldon-Dean explains.

‘Snail’ mail/memory device combo: If you send the patient an electronic copy of his medical records, such as on a CD or memory stick, via traditional mail, be sure to encrypt the data to “prevent accidental exposure in the mail, unless the patient requests that there be no encryption,” Sheldon-Dean advises.

Whichever option the patient chooses, be sure you explain the risks to the patient and document his consent.

Best bet: Try to be flexible; offer the patient all of the above options to access her medical records, if you have the bandwidth to do so.

Allow for ‘Face Time’ With Patients Who Dispute Record

When a patient accesses her medical record, there is always the chance that she will challenge the contents of it. Should a patient challenge your records, you have to be ready to respond via a practice representative that knows the patient’s record and is qualified to speak on the practice’s behalf.

Patients with concerns about their medical records should feel welcome to discuss the issue with the practice, Ciletti says. “We will sit down with them and go over their concerns,” she says. Often, these meetings result in greater patient understanding, according to Ciletti. “Sometimes [the misunderstanding] is language the patient doesn’t understand. Sometimes [the record] was dictated wrong,” she says.

If the practice committed the error, however, a meeting with the patient can also help restore patient confidence. If the practice has made the mistake in the patient record, a face-to-face meeting with the patient is the best way to handle the situation. This will show the patient that you are aware of, and concerned about, the issue.

Put Patient Record Disputes atop Priority List

To stay as open and honest with patients as possible, you should also offer multiple options for patients to respond to what they see as a medical record error.

Once again, this course of action will protect you legally and improve patient relations.

“The practice must, under HIPAA [Health Insurance Portability and Accountability Act], have a process for receiving and acting on requests to amend records,” Sheldon-Dean says. This process can involve more work than a medical practice might expect.

“[The practice] must be able to receive the request and act on it within 30 days, with a 30-day extension available” under certain circumstances, Sheldon-Dean says. Further, if you accept the patient’s request to amend the medical record, you have to notify any entity that might be relying on the un-amended information as soon as you can.

If you deny the patient’s request, the patient might file a statement of disagreement with the practice, Sheldon-Dean says. If the patient files such a statement, you must include it in the patient’s medical record.Your practice “can also file a rebuttal [to the statement of disagreement] in the record, but it must provide a copy of that [rebuttal] to the patient,” Sheldon-Dean advises.

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