MDS Alert

Question: Can we just hand out residents’ individual medical records willy-nilly upon resident or family request?

Wisconsin Subscriber

Answers: Providing individuals with the ability to access and obtain a copy of their health records may seem easy, but it’s more nuanced and complicated than you might think, experts suggest. “Regardless of the seeming simplicity of this access right, there are numerous requirements contained in the HIPAA regulations and OCR guidance that may ensnare unwary covered entities,” Wilkinson says.

Refresher: HIPAA requires covered entities to provide their patients with their protected health information (PHI) within 30 days of a request. Though CEs can ask for an extension, it must be in writing, and they can only ask for an extension once per patient request.

You always need to have a process for people to ask for copies of the information in their designated record sets (DRS), advises HIPAA expert Jim Sheldon-Dean, founder and director of compliance services at Lewis Creek Systems LLC in Charlotte, Vermont. And you must have a reasonable cost-based fee for furnishing the copies.

For instance, if a resident wants to get a copy of his clinical records, you would give him a copy of whatever is in his DRS, Sheldon-Dean explains. And if the resident wants to amend his records, you would amend whatever records exist in the DRS.

Why? Value-based initiatives have put patients’ rights — and, thus residents’ rights — at the forefront of healthcare, and easy, affordable access to files falls under the umbrella of quality care. Plus, “providing individuals with easy access to their health information empowers them to be more in control of decisions regarding their health and well-being,” insists OCR guidance.

Health IT and regulatory reform have also made it easier for CEs to coordinate care, share data, and offer this information to their patients.