Hey all, skip to the last paragraph for the TLDR version.
I recently had a procedure done that had me stay overnight in a local hospital. Everything went very well, and I was overall quite impressed by the skill and professionalism of everyone who worked on me.
Except one. There was this one young resident who, well, I don’t really know what was going through her head, but if she was on Scrubs, Dr. Cox would be riding her ass for months over some the stupid shit she did with me. It was upsetting, but I figure that since her unprofessional behavior was so distinct from everyone else’s there, she’ll either get corrected or be kicked out of the program without me having to raise any kind of stink.
However, a couple of off-hand comments my regular GP made while looking over my records had me wondering what the hell that resident put in her notes. At the time, I just made a dismissive comment and refocused my GP’s attention on the medical followup. Now, however, I’m concerned that I may be facing a “Johnny can’t read” situation, with some bullshit in my medical records that may influence how doctors deal with me in the future.
So, I know I’m entitled to my “medical records”, and I can follow the procedure listed on the clinic’s webiste, but I’m more interested in the practicalities of the situation. How do I actually go about getting all of the records, or at least the ones from the hospital, without causing any undo concern that I’m the litigious sort? And how do I go about correcting any false, or heavily spun, information contained therein?
I tried to get my medical records after a very bad experience last year (where they didn’t provide me with the results to a questionable pap in a timely manner. I’m trying to conceive, so that’s very important).
Basically I was told (and this was corroborated) that my records are actually their property. I was told that I can get copies, but I have to fill out paperwork and pay for the copies, and it would take a couple of months. They make it impossible for me to even take a look at them. At the time I was so pissed off and distraught that I just left.
Once I found a new doctor, I explained the situation and she told me that they were within their rights. They ‘own’ the records - the paper it’s on and the electronic files they keep. They don’t have to give me that original copy if they don’t want to, but I can request copies of it.
Anyhow, my doctor filled out a form requesting my records and about 8 weeks later I got a letter from the old clinic saying that if I want my records transferred, I have to pay $200. So fuck that. Luckily, I usually got a copy of any test results and was able to just give my new doctor those along with a personal health history.
YMMV and this is in Canada.
Edit: Upon reading of the ENTIRE thing, this isn’t really what your asking. I would ask your GP if you can take a look as a first step.
It probably is a good idea to talk with your GP before you go through a lot of trouble. If you have a good rapport with receptionist or office manager, they could also be a good source of information on how to get your records.
You don’t say what state you are in. Some states have laws allowing a patient to receive a free copy of his or her medical records. Other states limit the amount the provider can charge.
In a hospital, the records folks generally have nothing to do with patient care and will probably have no idea who you are. They are also frequently overworked and overwhelmed, and don’t really care. Requesting your records shouldn’t necessarily send up any kind of red flag. There are lots of reasons people request their records.
I’ve worked in a couple of jobs that required me to request medical records, but that is a different situation than requesting your own. I’ve requested my own records once, from a doctor’s office. I just called and said I needed my records for my new doctor (the truth). They told me to come in and sign their form, but agreed to mail it when I told them I had moved away. They mailed the form, I mailed it back, and they sent me the records in a couple of weeks, no problem. I believe that some places may require you to request your records in person, though.
I’ve pretty much exhausted my knowledge on the topic here. I just wanted to let you know that it isn’t always the disaster EmAnJ faced. Good luck.
From working in a hospital, specifically in the legal department, I can tell you than once you request your records, somebody from the risk management department will also be looking at those records, because the request itself is kind of an alert, even though it mostly does not signal impending legal action. (They will likely be looking at a version that has identifying information removed.)
In my state, people have much better luck if another doctor’s office requests the records, rather than the patient. I have gotten it done without even havnig to pay copying charges, although I was prepared to do so if I needed to. Copying charges are not supposed to be “unreasonable.” I would call EmAnJ’s $200 unreasonable unless her record was a thousand pages.
Also, in this state you have a right to look at the records, without having a copy made, and this shouldn’t cost anything. You have to request it in advance and go in during regular business hours–they might charge you for an appointment. This might vary by jurisdiction.
I’ve never had any trouble asking for and getting a complete and free copy of my medical records, although all of the institutions/providers I’ve asked have been either in a developing country or, if in the US, in Massachusetts, Washington DC, or Hawaii. So I don’t know much it is possible to generalize from my experience.
With that caveat: every time I’ve asked to be given a copy of my records, I’ve had the same straightforward reason, which has never been questioned: “I’m moving to [new country] and I need to take my medical records with me in case I need care there.” No one ever says “fine, give me the name of your health care provider there, and we’ll send them to the doctor in Timbuktu ourselves.” No, it’s much easier to hand over the records and let ME deal with it.
I don’t advocate lying, of course. And even if I didn’t care about ethical considerations, I’d feel obliged to point out that a bald lie could backfire, since I imagine that things could play out in such a way that you’d be caught in the deception.
Still, if you’ve been thinking about applying for a job abroad, or even just taking a very lengthy vacation…it’s possible you could use that to your advantage.
Just a quick note to say that I have requested my medical records from various providers and have had no trouble whatsoever, and didn’t have to pay the copies either. (The medical records were from Texas.) I just sent a short letter, which included my full name, birthdate and social security number:
I will say, however, that you are not really guaranteed that you will actually receive ALL of your records. I work in a law firm and routinely request medical records, and sometimes we issue subpoenas for the same records. You would be *AMAZED *at how the records department mysteriously finds loads more records once a subpoena is issued.
I went ahead and just requested my records today. I had to pick up a prescription, and so I decided to go ahead and see how the process would go for me.
I said to the receptionist, “I have some questions about getting a copy of my medical records…” and she handed me a form before I could decide what to say next. I took like five minutes to fill out (about a minute for those who are familiar with these things or don’t care to read all the instructions/fine print). There was a list of reasons for the request, like “legal” or “travel”, and I just checked the box that said “personal”.
She said that it might take up to a week for me to receive the records, and there was no mention of cost.
It went very smoothly, and now I’m guessing that people are more routinely asking for their records these days.
Hopefully there won’t be anything in the records to be concerned about, but if so, I’ll have to look at my options for getting that corrected.
When I moved from MA to NY, I called both my eye doctors, dentist, and the surgeon who did my back surgery. I told them I would be coming in to pick up my complete medical records in one week. On the day I indicated, I went to each office and picked them up. The only one I didn’t do that with was the GP because I didn’t have anything in those records I was concerned about and I wasn’t due for a physical for a year.
None of them charged me. None gave me any grief. None made me fill out any forms because those forms were included when I started seeing them.
After my elbow surgery in June, I needed copies of my records for Aflac. Even though the procedure was a worker’s comp issue (I was concerned that worker’s comp would have an issue with it - not the doc), I was able to get everything from the surgeon, my therapist, and the health center where I had gone initially - all with no problem. The health center did charge me $5 though.
I can’t imagine any doctor’s office trying to hold my records hostage. That is something I just wouldn’t accept.
When I wanted the records for Aflac, the surgeon’s office did offer to send the records directly to Aflac for me but when I said I wanted them for my own reasons too, they had no problem and sent them on. The doc knew that I’m training in medical transcription and probably knew that I wanted to see them for that reason! I was actually appalled at how many mistakes were in there. They spelled my name wrong on one of them! Nothing was anything that would have hurt me though so I didn’t bring it to their attention. But, if the final exam graders from my school had read the surgical report, the transcriptionist would have failed.
Just a note to say don’t be surprised about mistakes. I read a surgery record once that said I was unemployed and living with my parents. At the time, I was a 35 year old college professor and hadn’t lived at home in 15 years. Obviously, it didn’t matter, but it was amusing. Where did the nurse get that?
Please let us know if there was anything juicy/interesting in the notes!
My surgeon was the type to dictate the visit while I was still there. At our second meeting, he said he had just given me my second cortisone shot. I interrupted him and let him know that it was my 3rd (my first was at the health center). He corrected it on the recording. He also corrected my age from 26 to 28. I checked both those notes when I got the reports. They were both still wrong.
I was a teeny bit worried about inconsistancies in the report hurting my Aflac claim. They didn’t. I’m sure Aflac is used to it.
They got the important stuff right.
It was really cool for me though. I transcribe a lot of reports (real - but sanitized) in my class (well - I was. The surgery didn’t work so typing a lot hurts). It was very interesting to read the same type of report, and to see how the SOAP format is used in the real world. Even though I know the reports I’m hearing are real, it still feels more real when it’s your own info.
Under the Health Insurance Portability and Accountability Act (HIPAA) here in the U.S. patients are the owners of their medical records. Beyond assessing reasonable copying costs, a healthcare establishment cannot withhold your any portion of your records from you for any reason.
