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Releasing Medical Records

Medical records are a peculiar type of business record. The physical record (paper, microfilm, or something else) belongs to the physician making the record or the employing clinic. The information belongs to the patient in the sense that the patient has a right to control the release of the information to self and others. Some states limit the patient's access to potentially damaging psychiatric information, but in general the patient has a right to the information in the medical record. The parent or legal guardian of minors and the guardian of an incompetent adult may exercise this right on behalf of the minor or ward.

The physician does not need the patient's permission to report communicable diseases, unusual outbreaks of illness, child abuse, violent injuries, or other legally reportable conditions. In most other situations, the physician should not release information from the patient's chart without the patient's written permission. At the first patient encounter, the physician should have the patient sign an authorization to release information as necessary for the patient's treatment. This includes release to consulting physicians, laboratories, and other health care providers.

The physician must always have the patient's permission to release information for nontherapeutic purposes--for example, collecting insurance, determining job fitness, documenting sick leave, and other situations in which the release of information is not related to the patient's medical treatment. The physician should ask the patient to sign a written authorization to release this nontherapeutic information. The written permission should be dated, state to whom the information is to be released, which information may be passed on to that party, and when the permission to obtain information expires.

With the growing concern over AIDS-related discrimination, some patients will not authorize the release of their medical information to third parties. If the patient refuses to release information to consultants or other necessary medical care providers, the physician may not be able to manage the patient's condition properly. (This is the same ethical dilemma as a patient who refuses necessary medical treatment.) The physician has no right to release the information without the patient's permission. Conversely, the patient may not coerce the physician into rendering improper care. The physician should inform the patient of the problem and document this in the chart. If the physician refuses to treat the patient on this basis, the patient must be informed of the medical rationale for this refusal.

A physician has a duty to ensure that information is released only to properly authorized individuals. Assume, for example, that a patient has signed an authorization to release information to an employer. The physician can legally release information to the employer, but he or she must ensure that the person requesting the information is the one authorized to have it. This might require that the information be sent to the personnel department rather than be given to a caller on the telephone.

If someone presents an authorization that the patient has signed, the physician should endeavor to determine if the release is valid. If the release is over a few months old or appears irregular, the physician should attempt to contact the patient before releasing the information. If the patient cannot be located, the physician should contact the person seeking the information and try to verify the authenticity of the release. If the physician is still suspicious, he or she should request the person seeking the information to have the patient contact the physician.

A physician has a right to charge a nominal fee for a copy of the patient's medical record. This fee should reflect the actual charge for copying the chart. If the patient is indigent, the physician should provide the chart at no cost. Under no circumstances should the physician attempt to hold the chart hostage for an unpaid medical fee or to prevent the patient from seeking care elsewhere. This is bad public relations and may cause the patient to sue to obtain the record.

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