OBTAINING MEDICAL RECORDS FROM AN ACUTE CARE HOSPITAL/ER

When a patient wants copies of their medical records, that of a minor/child or person they have POA for, or in the case of a deceased family member...........

Here are the exact documents that you need to ask for. When you present the Health Information Management Department (aka Medical Records) Release of Information department with such a detailed ROI (release of information) they will take notice and "think" or "feel" that you know something and are not the general lay public/patient. Sometimes this could work against you as it forewarns them that you know your stuff.

WHAT TO ASK FOR:

Discharge/Death Summary (dictated report by attending physician)
History & Physical(dictated report by the admitting physician)
All Consultations (dictated reports or handwritten notes of specialists seeing the patient during this stay)
Physicians Progress Notes (daily entries made by the physician after he sees a patient)To include consultants notes in brief.
Physicians Orders (documents what the physician ordered for the patient..i.e. medication and dosage, therapies, consultations, any ancillary testing such as lab, radiology, etc....
Nurses notes(notes made by nurses only after they see the patient) Many times these are computer generated and very nice to read!
Medication Administration Record (MAR) (will list ALL medications that the patient was given during this stay with the dosage and time given)
Intake/Output Record (documents urine output if being monitored and what was taken in orally if this is being monitored)
All Radiology Reports (CT, MRI, X-ray, Ultrasound, Nuclear Medicine, special studies)
Respiratory Therapy Notes (made by the respiratory therapists including respiratory treatments and medication administered)
Other Therapists notes (speech therapists, Occupational therapists, etc....)
Operative Procedures:
- Dictated Operative Report (done by the performing surgeon)
- Anesthesia Record (completed by an Anesthesiologist or CRNA- nurse anesthetist)
- Recovery Room Records (completed by OR nurses and physicians)
- Pathology Reports (documenting status of any tissue removed i.e. type of malignancies, benign tumors, etc....will give staging of Cancers as well-tissue report.)
- Sometimes a second opinion is requested on a pathology report and the tissue specimen is sent out to another facility. In this case it can take weeks to get the second opinion back. These should be dictated typed reports done by the Pathologist.
Coding Summary (is diagnostic and procedural information used for billing purposes. Is completed by Coders in the Health Information Department) will show in detail all of the patients Diagnoses and Procedures at the time of discharge.
Face Sheet (generally is just demographic patient information such as address, billing insurance info,etc..)

This is a basic medical record. Things such as OB/GYN have different forms in addition to these standard ones. Newborns & Pediatrics also has it's own set of forms to use as will other specialty areas.

An ER record can be obtained by itself if this was the only visit by the patient. Just ask for the entire Emergency Room record including a dictated ER report by the ER physician. Also ask for consultations if any were made while in the ER. Lab results, Ancillary reports as necessary.

You can also obtain a single report such as any Radiology test that was performed. You usually get these from either the Health Information Management Department or directly from Radiology depending upon each hospital's ROI procedure. You can also obtain copies of your X-ray films through the Radiology Department. They should never release the originals, only give you copies.

Please remember to allow notice to obtain any copies requested. No HIM department will give them on the spot to you. They need at least 48072 hours notice depending upon their specific guidelines. Also keep in mind that if you request copies of a patients inpatient record immediately upon discharge, it will be incomplete awaiting dictated and transcribed reports. This will delay obtaining the entire record. They typically will wait till all necessary dicatation is placed onto the patient chart before releasing the complete record.

Same holds true for Ambulatory Surgery/Same Day surgery records.

It is very important NOT to disclose any legal uses for this information. If you do say this, the red flags will go up and the record will be placed in the Risk Management Department in a locked file. Hospital attorneys will be contacted and everyone will be on "alert" that a pending lawsuit may follow.

Attorneys will charge you a fortune to obtain these copies for you. Do it on your own.

Cindy
South Subs of Chicago