It is your absolute right to have all of your medical information in your hands, including your medical history, diagnostic lab & test results, current treatments, and any operative notes.
Accessing Physician Records:
Make a list of all of your physicians along with their email address, telephone and fax numbers. Call, email or fax each office and request a list of your diagnosis(es) and recommended treatments, in addition to any diagnostic lab or test results. You have a right to a copy of your records. This is sometimes cumbersome for the office, but it is your right to have the information. Keep in mind that you ( or your health insurance company) have paid for these tests and you own the information.
Accessing Hospital Records:
If you are a patient in the hospital, you have the right to access your medical chart at any given time. Since there will be medical terminology and abbreviations in the chart that you may not be able to understand, the best way to accomplish this is by asking your nurse to go through that information with you. According to the Patient Bill of Rights, the facility is required to provide you or your patient designee, upon request, access to all information contained in your medical records. This access may be restricted by your attending physician for sound medical reason only. If the physician restricts your access, he or she must record the reasons for such restriction on your medical record. In many cases, your designee may have access to the information in the your medical records even if your attending physician restricts your access to those records.
You are also entitled to have copies of all of your medical records. Don’t be afraid to ask for them. Generally, hospital policy is to not provide any medical records until discharge, but there may be times when you need access to those records before discharge. You may have to fight for that access and you will need to be polite, yet firm, regarding your request. Legally, neither your doctor nor hospital can refuse your request, although they may charge a fee for making copies of the information. Be prepared to fill out a request form in order to obtain your records. If you have already paid for a copy of your Xrays from your doctor, make sure you let the hospital know that so you don’t end up paying for them twice. Health care consumers do not commonly ask for their records, so while you must be firm in your demand, try to be understanding of the hospital clerk, other non-professional … and even the nurse…who might not have ever received such a request before. Stay calm and keep in mind that you have paid for your tests, you own the results and therefore, you have the right to have them. Call for a supervisor if your request is denied or if you are being given a hard time. Be assertive for yourself or your loved one. You have a voice… use it!
Anecdote:
My single adult son was seriously ill and required intensive care. We felt that a 2nd opinion to confirm the diagnosis was necessary and appropriate. We chose a doctor at a different facility and he requested to get a copy of my son’s records up through that day as soon as possible. I told my son’s evening nurse that I needed the records and she told me that she didn’t have the authority to do that. So I went to the unit supervisor who said that the hospital policy was that they didn’t give out records until after discharge. I suggested to her that she save herself a lot of aggravation and that she ask the hospital administrator to come down and speak with me. Twenty minutes later, the hospital administrator, the director of nursing and the head of medical records came to pay me a visit. I explained to them that I didn’t have any complaints, that I wasn’t unhappy with anybody or the care, but that I would sleep better if I had a 2nd opinion regarding my son’s grave condition. They gave me many excuses why they couldn’t accommodate my request that evening, and I explained to them that I had all the time in the world to listen to their excuses, but the bottom line is that we all know that legally those records are ours and we can access them at any time. I had a voice… I used it to protect my child. At which point, they asked me the fax number I wanted them faxed to. Within an hour, I had a hard copy of all the records I needed. You have a voice…use it!