Patient viewing your documentation

[letmesleep]

My own 2 cents would be to let the PT read the PCR. As far as I am concerned they get to read what I have written because it is a part of their medical records, however a COPY of the PCR would have to be requested through my admin.

With that said I will allow PT to read the report, but only the pt......not their family. If there were any changes and/or corrections requested by the PT, I would take them under advisement. In Ruffems situation, ths would be an example of a needed change for me, but documenting poor living behaviors is what it is. If they don't like it then they can clean their house or not request to read the report.

[Ridryder 911]

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!).

Actually no, they do not have the right. HIPPA which only involves those that perform electronic billing, is separate from the privacy rights. The chart and the information on the chart is owned and managed through the institution owning that chart or record.

Yes, most institutions allows one to see a copy or obtain a record after it has been processed (Notations, chart review, QA, Billing, etc. ) but not until authorized from the medical records or medical information division, unless they have other institution policies. Since many of the charting is now electronic as well, they will have to allow notations and printing as well. I know many hospitals have began charging for copies as well.

Patients must sign a waiver for information, where to send the chart, and how many copies being made, purpose, etc. Just because someone is a patient does not mean they have access to their chart, especially immediately. I know all the hospitals I have worked at has specific directions on that the patient cannot view their chart, even if they are staff or a physician. Most institutions even have regulated viewing on whom can see the chart within the hospital (i.e. someone from O.B. viewing a ER chart) it must be r/t care, or direct care of the patient. We had a nurse discharged for reading her own chart (electronically) without signing the waiver, another on probation reading about their son chart. Again, because of lack of waiver prior and authorization.

R/r 911

[pacman]

I'm afraid of letting my patient immediately read my PCR because I fear that he/she might damage or destroy it.

In one instance, I had a drunk patient screaming obscenities and being physically uncooperative. After I got the nurse's signature, the patient demanded to see my report. I knew I wrote things that he wouldn't be too happy about ( nothing personal) so I told him that he could request a copy of my report through the appropiate venues as soon as he sobers up. I then promptly left so I could go back to sleep. :x

[Doczilla]

A patient has the right to view medical documentation as it pertains to them at any time so long as the document is complete and signed (alluding to Rid's preference that it be QA reviewed. The signature implies that you have reviewed it and it is correct to the best of your knowledge.). You can make them go through the rigamarole of requesting it through the agency or medical records department if you like, or tell them they need a court order (which isn't true). Making them go through this, however, makes it look like you have something to hide. If there has been a bad outcome, this is only worse for everyone.

It's much better for everyone if you just let them see it, so long as they would have the right to the information, (i.e., the patient themselves, or the POA or next of kin if the patient is not competent). As Rid said, it's a good idea to have them sign a release of information form.

1) They should never be left alone with the documentation. If they view it, it should be in the presence of an employee of the agency, preferrably a medical provider who can explain things they don't understand and answer any questions they may have. Because we frequently write in medical shorthand, it will be necessary to translate some abbreviations. (na, ma'am, that's Shortness Of Breath...)

2) Any request by the patient (or family, as appropriate) to view the medical record should also be documented with date, time, and who was present.

3) The chart is the property of the healthcare organization (though the patient or appropriate representative may view it any time), and the patient therefore cannot alter it. As someone else stated, they may dispute the documentation, and this may be noted in the chart.

4) If they want a copy to take with them, they should then go through the agency to obtain one. This entails signing a release of information form that is kept on file.

5) A court order is only necessary to release the information to someone who would not otherwise be entitled to it, i.e., a family member that is not the healthcare POA or generally accepted next of kin (in the case of an incompetent patient).

'zilla

[n5iln]

How interesting that this thread should come up right now, considering a call I had early this morning.

Scenario: Called to a proprietor home (not to be confused with a nursing home) for an evaluation of a resident that tripped and fell. We're told on arrival that this is a new requirement for the proprietor home; ANY resident who falls must be evaluated by qualified medical personnel, even if it's obvious that the only result will be a patient refusal.

Patient is evaluated, all findings are within normal limits for the patient...not so much as a scrape or bruise. We complete the PCR and the required refusal form and obtain patient's signature on both indicating patient does not wish transport. Staff member then tells us they need a copy of the refusal form to document that patient was evaluated and refused transport. We refuse to provide a copy, indicating that the form falls under HIPAA as a medical document. Supervisor backs us when the staff member calls to complain.

Something tells me this is going to mushroom in a hurry.

[VentMedic]

EMS Refusal of Care forms greatly need to be examined for their adequacy.

I am not attacking anyone's care here, especially if they are just following protocol. With that being stated...

In most situations when a patient refuses treatment and/or transport, EMS fails to meet the standard of care of most other medical professions. Normally, a crew member retrieves the clipboard and obtains a quick signature from the patient, telling him, "Sign here. This says you do not wish to be transported to the hospital." After a signature is obtained, the crew leaves and returns to service.

If a patient signs a refusal, can your system prove that your responders provided the patient adequate information and advice? More important, what specific advice did they provide?

There are systems that either provide a specific information sheet or write specific instructions on the Refusal Form. The patient is then signing not only a "Refusal form" but that they have been given a form with some specific instructions.

Nursing Home personnel also would like show that you did more then walk in, take a refusal and leave.

I did just see this issue discussed in a recent journal. This issue actually has very little to do with HIPAA, but rather it is more of a "transfer of care" issue between two healthcare providers. This is similar as to when you hand off a copy of your PCR to the ED. For the patient, new forms with specific information now show you have transferred the responsibility to patient that he/she was informed and he or S.O. can read about it again if he forgets what you said. You may also see an improvement in "transfer of care" for the patients (BLS routine) that are picked up at hospital to be transported to other facilities, ie nursing homes, dialysis, HBO etc.

HIPAA is pretty specific for certain data. However, for direct patient care, hospitals and nursing home have other accrediting agencies that are directly related to patient care information that they must abide by. General Privacy rules still apply.

[n5iln]

You have the right of it in many, many cases. However, the regional Medical Director anticipated this very issue, and included a requirement in the regional protocols that mandates a PCR be completed for each and every dispatch, no matter the final disposition...transport, refusal or cancelled call. And in the case of a patient refusal, we are required to complete a primary survey, obtain at least one full set of vital signs, and complete an appropriate focused exam based on the original nature of the call and any complaint the patient presents. And all refusals are reviewed by the CQI committee. Additionally, it's a company policy that all refusals are cleared and logged by the duty supervisor prior to the crew departing the scene, unless remaining at the scene would cause further difficulties (as in the case of a domestic assault, in which case the police take over where we leave off).

Based on this requirement, I consider a refusal form part of the medical documentation for the run, and therefore covered as privileged patient information under HIPAA.

[Just Plain Ruff]

I believe you also have to provide a patient with the risks and benefits of refusing care. They need to be documented on the run ticket and a copy given to the patient.

I'm not sure what the legal ramifications of not providing these risks and benefits is but I would think if a patient signs a refusal you need to provide the risks and benefits.

Just my two cents.

[n5iln]

I believe you also have to provide a patient with the risks and benefits of refusing care. They need to be documented on the run ticket and a copy given to the patient.

I'm not sure what the legal ramifications of not providing these risks and benefits is but I would think if a patient signs a refusal you need to provide the risks and benefits.

Just my two cents.

There's a separate sheet we provide the patient that contains all that. It comes to us stapled to the refusal form, along with the HIPAA notice.

We're sort of backwards in a lot of areas, but we've learned to be proactive with things that can land us in court...

[Just Plain Ruff]

that sounds like you have it in hand there. Refusals really are one of the most sued over reasons out there.