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Message #642 Getting medical records

mp3 #642 Can You See Your Medical Records? (mp3 file)


In the past, your health records were considered to be property of the physician who compiled the notes and reports, and you as the doctor's patient could obtain your medical records only if your physician gave permission, or if you obtained them through an attorney or by court order. It used to be very difficult to obtain your own medical records, if your doctor or hospital was unwilling to give them to you.

Since 1983, however, California law now gives you the right to inspect and obtain copies or summaries of your health records, without an attorney, and without getting a court order. The statute, called "patient access to health records," is found in California health and safety code sections 1795 - 1795.26. The law says that you have a right of access to complete information about your health condition, and the health care you receive.

This message will discuss the following questions:

1-Who may request and receive health records?

2-Who is required to give you health records?

3-How do you make your request?

4-What can you expect to receive, after making your request?

5-May a health care provider give you a summary report, instead of a copy of your original records?

6-May a health care provider refuse to let you see certain records?

First, who may request and receive health records?

You yourself may ask to see and receive copies of your own health records, if you are an adult patient or a former patient. If you are a minor patient, under the age of 18, you may also see and receive copies of your own health records for health care of the type that the law permits you to consent to your own medical treatment. If you are a parent or guardian of a minor child, you may see and obtain copies of most of your child's health records. If you are the guardian or conservator of the person of an adult patient, for whom you are responsible for making health care decisions, you may see and obtain copies of that person's health care records.

Next, who is required to give you health records? You may request health records from any hospital, nursing home, clinic, home health agency, physician, podiatrist, dentist, optometrist, chiropractor, marriage-family-and child counselor, or clinical social worker. These facilities and professionals are called "health care providers."

Next, how do you make your request? If you want to inspect health care records, you present a written request to the health care provider, specifying the records you want to look at. You are also required to pay for reasonable clerical costs in locating and making the records available to you. If you want copies of health care records, you present a written request to the health· care provider, specifying the records you want copied. You are also required to pay up to 25 cents a page for copying costs from paper, and up to 50 cents a page for copying costs from microfilm, plus any additional reasonable clerical costs in making the records available for copying. You are not personally entitled to receive copies of x-rays, or tracings from electocardiograms, electroencephalograms, or electromyograms, if the originals are sent directly to another health care provider of your choice. Again, a written request is necessary, stating the name and address of the other health care provider to whom the original x-rays are to be delivered. You must also pay the reasonable, actual costs for sending x-rays.

Next, what can you expect to receive after making your request? If you have asked to see health records and paid the fee, you have the right to inspect them during normal business hours, within five working days after the health care provider receives your written request together with your fee. You must personally make the inspection, and you may bring with you one other person of your choice. You should be prepared to show verification of your identity, to the health care provider.

If you have asked for copies, of all or a portion of certain health records, and have paid the fee, the health care provider must send you the copies within 15 days, after receiving your written request together with your fees. X-rays must also be sent within 15 days to another health care provider. If your health record is lengthy, you may wish to inspect it first to decide which pages you want copied, to avoid the high cost of copying those pages that you do not need.

If the health care records you seek are quite old, the records may have already been destroyed. State laws and regulations do not require health care providers to keep all patient records indefinitely.

Any health care provider who willfully fails to permit inspection, or provide copies of health care records, is considered guilty of unprofessional conduct, and is subject to disciplinary action, including suspension or revocation of the state license to practice his or her profession. For certain health care facilities, it is also an infraction, punishable by a fine of up to $100.

Next, may a health care provider give you a summary report, instead of a copy of your original records? Yes, a health care provider may choose to prepare a summary of your health care record, instead of allowing you to see or copy the original record. A summary must be made available to you within 10 working days of receiving your written request. However, the time period can be extended to a total of 30 days, if your request is made within 10 days after your discharge from a health care facility, or if your records are of extraordinary length. You will have to pay a reasonable fee for the summary, based on the actual time and cost for the preparation of the summary. The summary must include certain detailed information about each injury, illness, or episode, for which records are requested, including the following:

--chief complaints and related history

--reports from consultations and referrals to other health care providers

--diagnosis

--treatment plan and medication

--progress of the treatment

--prognosis, including continuing problems or conditions

--reports of diagnostic procedures, tests, and all discharge summaries

--objective findings from the most recent physical examination, such as blood pressure, weight, and actual numerical values from routine laboratory tests, and

--all current medications prescribed, including dosages and any sensitivities or allergies.

Next, may a health care provider refuse to let you see certain records? Yes, in some circumstances, a health care provider may refuse your access to certain records. For example, as a parent or guardian of a minor child, you may be denied access to those portions of your child's records for health care of the type that the law permits minors to consent to their own medical treatment. Also, your child's health care records may be denied to you as a parent or guardian, if the health care provider determines that your access to the records would have a detrimental effect on the provider's professional relationship with your child, or on your child's physical safety or psychological well being. Another example is mental health records, where access can be denied if the health care provider determines that there is a substantial risk of significant adverse or detrimental consequences to you as a patient, if you see or receive a copy of your mental health records. If mental health records are denied for these reasons, however, you as the patient must be informed that you may choose another physician, psychologist, or clinical social worker, to whom the mental health records will be sent.

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