Under new administration guidelines, the physician is not allowed to require the patient to state a reason for the request, nor can the physician deny a request for medical records by a patient who has failed to pay his medical bills. The physician’s office may charge the patient a nominal or reasonable fee to cover the cost of the copying, but may not charge for staff time required to locate the records. A physician may not be required to provide a typed translation of handwritten notes, although egregious handwriting may prevent the patient from full access to his medical information. In such a situation, it would be appropriate for the physician to spend time with the patient reviewing these handwritten notes, giving adequate explanation to ensure the patient’s understanding of his health status as noted in the record.
Explore This IssueApril 2016
For a variety of reasons, many patient medical records—whether they are electronic or handwritten—will contain incomplete information, omissions of fact, or outright mistakes. This can especially be a risk when a physician takes home 30-plus charts at night to make written or electronic entries. Who can remember the exact details on each patient? It is quite ethical for the physician to be receptive to a patient’s review of his medical records, whether periodic or in toto, to allow for amendments of the records or addenda to reports. (This author has been cared for by an orthopedic surgeon who dictated the entire patient encounter at the end of the consultation and then asked the author to make any needed corrections to his statements.) Time constraints in the office may be a major deterrent to the accurate documentation of the medical history and clinical examination, although the rigidity of some EHR programming may also be complicit.
The Physician’s Role
While it is understandable that some patients might have concerns about other healthcare entities’ access to their PHI, including office staff, the amount of information requested in this scenario about the scope of access appears to fall outside of a “reasonable accommodation.” However, this case does point out the importance of the physician’s keen oversight of those staff members who participate in the recording of a patient’s PHI, especially the background, capabilities, and trustworthiness of a scribe. The veracity of the information input by a scribe is not only important to the patient’s clinical care, but also to the legal integrity of the documents. The patient is entitled to know how much responsibility is given to a scribe as well as the level and extent of the physician’s oversight of the information the scribe inputs into the EHR. Failure to identify