Your medical records are more important than you think.
It's no secret that when you go to a doctor, he will create a patient file for you. These used to be paper files. Files with medical tests. Files with progress notes. Files with blood work results. Nowadays, your medical information is likely going to be stored in electronic medical records. On a computer. On some server. Somewhere. Maybe in Hillary's basement server. (That's a joke in case you couldn't tell.)
Your electronic medical records contain some basic information about you. It will likely have your height. It will have your weight. Your medications you are taking. Your past medical history including any diseases and infections you've had. It will have comments and notes by your doctor about your complaints. About your plan of treatment that your doctor recommended.
You might think that if you need copies of your medical records it would be easy to get, right? Just have the secretary at the front press 'print' on your entire medical file and give you a stack of your printed medical records. It should be that easy. But it's not. You probably never thought about it, but having your medical chart on hand is absolutely essential for many reasons and it is not always easy to get.
What if you felt that your doctor did something wrong and you wanted your medical records but the office said no?
Maybe you decide it's time to move on to another doctor...for whatever reason. You now want Doctor #2 to have a copy of all your records from Doctor #1. You want your new doctor to be able to get up to speed on everything that's gone on with you recently. You want to show up in Doctor #2's office with all your prior medical records. This way, doctor #2 can read those records when he has time and formulate an accurate treatment plan.
When you go to another doctor, the office staff will often send a request to your first doctor to get copies of your records. That's often a quick way to get your records transferred. It's often faster than you getting them. Plus, you don't pay any fee to doctor #1 for photocopying charges. Doctors offices typically send medical records to other doctors offices without charging customary fees.
If you were to request your records directly, your doctor's office would demand that you pay photocopying charges. But what happens when your doctor's office refuses to release your records, either to you or to your new doctor? It sounds bizarre but it's true. There are numerous cases where a doctor’s office refuses to hand over a patient’s medical records to the patient. Is this right? Patients should have access to their medical records. What can you do if this happens?
In New York physicians are required by law to give you copies of your medical records when you ask for them.
You expect your doctor to give you the original paper file when you ask for it.
Sorry, but that's not going to happen. You might think it will, but that's not how it works.
Let's assume for a moment that your doctor's office still maintains a paper file for your medical records. You will not receive the original paper file. You will not receive the doctor's notes in his original handwriting and ink. You will not receive your blood test results that have the doctor's original signature approving the results. Instead, your doctor's office will make photocopies of your medical records.
They will give you copies. After they charge you a fee for photocopying your entire chart. The doctor's office will never release your original medical chart to you. They are required to keep that original chart in their possession at all times. They are required to maintain your chart in the ordinary course of business. They are required to use reasonable means to safeguard the contents of your file.
If your doctor's office uses electronic medical records, there is no 'original' chart. There are electronic, computerized records. They are date stamped. They are time stamped. There are electronic trails left anytime a doctor or staff makes an entry in your electronic record.
When you request copies of your electronic medical records, you must ask for your entire electronic record.
If you don't, there's a good chance the doctor's staff will only give you selected portions of your complete record. No matter which method of record keeping your doctor's office uses, there is a specific procedure you must go through in order to get your medical records. You must make a written request for your records. You must give your doctor's office permission to give you copies of your medical records. It's a standard form they'll ask you to fill out.
It takes only a few moments to fill it out and sign it. If they dont' have a form, simply write out this sentence "I hereby give permission for my doctor, Doctor Jones, to release copies of my medical records to me immediately." Then sign the page and date it. Will your doctor's office staff do this for free? No. Your doctor will ask you for a copying fee. He is legally entitled to charge you, the patient, for a reasonable per-page fee to copy your records.
He is entitled to charge you a reasonable fee to have his office staff stop what they are doing and get your records copied to either hand them to you or mail them to you.
Once you provide him a check or some form of payment for that fee he will officially be obligated to provide you with the copies of your medical records. What do you do if your doctor still does not give you your records ever after you paid the copying fee? You think this doesn't happen? It does.
Sometimes a doctor might think that you are going to sue him for medical malpractice. He might not want you to get copies of your medical records. Maybe he has something to hide. Maybe he thinks if he delays giving you your records, your time to file a lawsuit against him will run out. Maybe he thinks if he delays giving you your records, you'll forget about it. Whatever the reason, you're now stuck in the predicament where your doctor is refusing to turn over your medical records.
What options are available to you at that point?
If this happens to you, you need to take your written request letter along with your permission form, known as a HIPPA authorization and mail them to the New York State’s Department of Health. In your cover letter, you need to let the Department of Health know that your doctor is refusing to release your records. Make sure you copy your doctor on the letter. This way, he'll know that it's only a matter of time before he must release your records.
Once you do that, you are essentially asking the Department of Health to help you obtain copies of your medical records. That will trigger the NYS Dept. of Health to send a letter to the doctor inquiring why he is not complying with the law. It is important that you make it clear to the Department of Health that you requested your medical records from your doctor’s office, followed the appropriate protocol outlined for making that request and yet your doctor’s office has repeatedly not honored his obligation to release your medical records.
What will the Department of Health do?
The Department of Health will contact your doctor’s office to find out why they have not yet released your medical records. At this point the Department of Health will inform your doctor’s office that he must comply with the law and release your records. There are penalties for refusing to release patient records.
Why is it important to be aware of this protocol?
This type of problem is actually quite common. Often times a patient gives up after their doctor’s office does not give them their records rendering them unable to find out whether they were treated appropriately.
In the story below, you will see an example of a doctor who refused to give the patient copies of his medical records. The patient's family felt that this refusal led to his new doctors being unable to provide him with the necessary medication and treatment plan since they were treating him blindly.
CNN reports on a serious case where medical records were at stake in saving a man’s life.
Mrs. Holliday pleaded with doctors to hand over her husband’s medical records as he lay in bed dying from kidney cancer. She desperately waited for these records for five long days. On the sixth day her husband needed to be transferred to another hospital for treatment as his condition had become so dire. He was going to be transferred without his complete records. What did this mean for the Hollidays?
Without Mr. Holliday’s complete medical records the second hospital would not be able to properly medicate him. It is important for them to be able to see his whole history before starting any treatment plan, especially in case he had an adverse reaction to specific medication.
Mrs. Holliday tearfully told CNN, “When Fred arrived at the second hospital, they could not give him any pain medication because they didn't know what drugs he already had in his system, and they didn't want to overdose him. For six hours he was in pain, panicking, while I ran back to the first hospital and got the rest of the records."
What does federal law say about medical records?
Federal laws (in addition to state laws) also require hospitals to produce medical records when requested but still many hospitals and doctor’s offices fail to do so. This can lead to dire consequences. You would be surprised to know just how many complaints the Department of HSS gets about physicians who do not comply with legal requests for medical record copies.
CNN reports, “While there are no statistics on how many patients have trouble accessing their own records, there have been ‘repeated’ complaints to the Department of Health and Human Services, according to a senior health information privacy specialist at the department's Office for Civil Rights, which enforces the federal law that gives patients access to their records.”
CNN recounts a story of one patient who endured having the wrong kidney removed after going into the hospital for removal of his cancerous kidney.
As a result of this negligence the cancerous kidney remained in his body. How did this grave mistake happen? The horrific error occurred because the side with the effected kidney was marked improperly in the patient’s medical chart. Are you starting to see the importance of obtaining your medical records and having accurate records?
So what happened with the Hollidays?
Mrs. Holliday went to the first hospital again after her husband’s transfer with her power of attorney over her husband under her arm. She told CNN that she basically had to get ‘nasty’ and fight with the hospital to finally get the records. The second hospital finally gave her husband more pain medication after receiving the second chart. Unfortunately, Mr. Holliday passed away two months later at the age of thirty-nine.
“After he died, Mrs. Holliday, an artist, painted a scene on the back of a jacket depicting her husband in a hospital robe and handcuffs with the words ‘Data Prison’ above him,” according to CNN.
How many medical record horror stories are there out there?
CNN also discusses the story told by a CEO of a high-tech company, Mr. Viars.
CNN explains, “Viars says he learned of the importance of looking at your own medical records when his father went for an annual physical last summer and his doctor told him an EKG test the year before indicated he'd had a heart attack. He says no one had ever told his father he'd had an abnormal EKG.”
How could this possibly happen? Isn’t a doctor at least supposed to read the report of the test they are conducting? Apparently that is too much to ask for. Mr. Viars told CNN, “His physician didn't bother to look at the result of his EKG or failed to inform my father of his condition.”
The bottom line...
It is important for patients to be their own best advocate in order to seek the best treatment possible for themselves and in that pursuit having your medical record on hand is often essential.
To learn about a doctor who altered a patient's medical records, I invite you to watch the video below...
What happens if your doctor alters your medical records during your medical malpractice lawsuit?
How do you lay a foundation to get medical records into evidence?
Can you review your medical records before your pretrial deposition?