Patient viewing your documentation

[Just Plain Ruff]

I'm curious as to what circumstances you would allow a patient to read your patient report or Documentation?

[Medic26]

None unless they have a court order.

[ladyemt51_2000]

Any of the reports I have ever written were written in mind that anyone, including the patient (or LE, court officials, ect.) could read them at any time. I am mindful of that when I write a report and stick to facts and remain brief, clear and exact as to the call, treatments and any other pertinent information.

As to circumstances, I believe a patient has full rights as to access to the documentation made of his or her treatment. Interesting enough, I was just reading a piece on AOL news recently about top 10 reasons why you should find another dr. and one of them was denial of access to medical records.

I am sure I am missing a few valuable points so I will be interested in watching how this pans out. Great topic!

[Just Plain Ruff]

I agree lady, I don't understand why physicians and medical services have such a hard time with allowing me to read my medical record. I should be able to review it for errors and misstakes just like I can review my credit report.

I don't think it requires a court order to get me to read my patient care reports like a previous person posted.

What happens if the provider marks down something wrong. Case in point.

My wife suffered a miscarriage about 6 years ago. The physician marked the wrong diagnosis (elective abortion) when it should have been spontaneous miscarriage or Threatened miscarriage. The insurance denied all our claims since they don't pay for "Abortions".

so shouldn't I or my wife have the right to dispute what is wrong with your documentation? It can directly affect what your insurance will pay for.

Just a couple of random thoughts.

[Ridryder 911]

I allow patient's to see my documentation after they sign the release then obtain it from the business office M-Fr 0900 to 1700 the following day, just like hospitals. It should be QA and reviewed first. It is about the patient; however, technically it is not the patients and are considered the property of the institution. They may purchase or obtain copies.

The reason being is yes, I document some personal facts of that patient, that the patient may want or find argumentative at that time, which is not time to perform. I may document the dishevelled appearance or poor living conditions as well as ill kept, grossly obese, over dramatization and inappropriate behavior, drug seeking tendency behavior, poor coping skills, rude obnoxious behavior, etc. Along, with my medical impression of the condition and physical findings, such as AAA, CVA, cerebral neoplasm, etc...

R/r 911

Ruff, actually your classification was an abortions (spontaneous not elective) but still classified as such.

[Just Plain Ruff]

Rid, true so true but when the hospital changed the diagnosis to spontaneous abortion the insurance paid right up. The physician just marked the wrong box on the diagnosis. He checked complications from elective abortion and not spontaneous abortion. There is a significant difference in those two terms.

It was the classification diagnosis of Elective abortion that the insurance company said NOPE aint gonna pay.

I'm not advocating that the patient get's to see the record right after I've written it. Not that at all. I'm advocating that I should be able to see it and correct any noticeable wrong information. In no way am I advocating that a patient be able to see the report immediately after you've written it. They have to follow channels like everyone else, fill out a medical records release of information at my companies business office.

[EMT City Administrator]

I believe HIPAA allows for review by the patient and "correction statements" from the patient to be added to their file after a written request to do so.

[chaser]

You can sign a medical release and have total access to your records.

You may be supervised to prevent you from taking or changing anything, but legally you can read anything you request.

I see a reason for having someone watching, I once had a patient run out of the clinic with their xrays :roll: .

Yes, this would be the dumb ass who comes back to sue later as "no one" has records of the films they now desperately need.

[Michael]

over dramatization and inappropriate behavior, drug seeking tendency behavior, poor coping skills, rude obnoxious behavior

Say, isn't Admin always asking us to recruit new members? 8)

[n5iln]

None unless they have a court order.

BZZZT...

As I understand HIPAA, the patient has the right to view ANY part of his or her medical records at ANY time, which means they (under the letter of the law) can read your PCR even before the ED sees it.

Now under the SPIRIT of the law, they need to go through the routine of requesting a copy of their records from the business office during regular business hours, just as they would with their records from a physician's office or hospital. And there's absolutely nothing in HIPAA that says they can make any changes whatsoever to those records (except to correct demographic information).

It would take a small team of lawyers to work through the details, and I'm a medic, not a lawyer (thank Ghu!).