Reviewing your own medical records after every visit is one of the best things you can do to protect yourself as a patient. Ensuring symptoms, medications and conditions are listed correctly can help shield against both potential misdiagnosis and medication errors. Bell Law Firm encourages you to take responsibility for the storage and maintenance of your own medical records, but what’s involved?
First, it’s important to understand your rights. According to the Health Insurance Portability and Accounting Act (HIPAA) of 1996, you have the right to obtain copies of most of your medical records, whether they are maintained electronically or on paper. These include doctor’s notes, medical test results, lab reports and billing information.
Who Can Request Medical Records?
According to HIPAA, you have the right to request medical records if:
- You are the patient or the parent or guardian of the patient whose records are being requested.
- If you are a caregiver or advocate who has obtained written permission from the patient. In some cases, the health care provider will provide you a form that the patient must complete.
Which Records Can be Requested?
You have the right to obtain most of your ordinary medical records, including:
- Any notes or records that a provider has created themselves
- Any diagnostic results for which a provider has copies including blood tests, X-rays, mammograms, genetic tests, biopsies, etc.
- Any information provided by another doctor that was used to establish a diagnosis and/or direct treatment.
There are some medical records that healthcare providers can withhold, which is important to keep in mind. Under the law, the following may be reasonably withheld:
- Psychotherapy notes
- EMR records that are not in a designated record set
- Records that might endanger your life and safety
- Information compiled for use in a lawsuit
- Records that includes mention of another person who may be harmed by the release of the information
- Records that breach the confidentiality of a third-party who was promised confidentiality
- Records that may compromise your health, safety, custody or rehabilitation
- Records that are part of ongoing research that has not been completed
How Do I Request the Records?
Some health care facilities will provide a form for you to fill out in order to request medical records. However, if a request form isn’t available, you can always write a letter to make your request. Under the federal HITECH Act, a patient has a right to obtain his or her records at minimal cost.
It is most useful to have your records in electronic format — as pdf documents that retain the original text data, with original color and image quality. With records in that format, you can easily search by keyword, which is very important because medical records can be long.
Under the HITECH Act, medical providers are required to give you copies in the format you ask for.
Be warned, however, that in our experience, medical providers routinely ignore their legal duty to give you copies in the right format. You may have to put up a fight just to get medical records in the proper, most useful format. (Ask yourself: Why would medical providers give you records in a harder-to-read, harder-to-search format?)
I Have My Records, Now What?
Once you receive your medical records, review them carefully for errors and omissions. If you think you or a loved one may have suffered from medical negligence, reach out to Bell Law Firm today.