Federal law is quite clear: a patient has the “right to obtain from [their health care providers] a copy of [their medical records] in an electronic format,” 42 USC § 17935(e)(1), and that health care provider is allowed to bill “only the cost of …[c]opying, including the cost of supplies for and labor of copying,” 45 CFR 164.524(c)(4)(i).(2) The hospital shall establish, implement and monitor an effective system of author identification for medical records and/or medical orders to ensure the integrity of the authentication and protect the security of all transmissions, records and record entries.
(7) The hospital shall allow patients and other qualified persons to obtain access to their medical records and to add brief written statements which challenge the accuracy of the medical record documentation to become a permanent part of the medical record, in accordance with the provisions of Part 50 of Chapter II of this Title and the provisions of Public Health Law, section 18(4). (1) The medical record shall contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient's progress and response to medications and services.
(2) All records shall document, as appropriate, at least the following: (i) evidence of a physical examination, including a health history, performed no more than thirty days prior to admission or within 24 hours after admission and a statement of the conclusion or impressions drawn; (ii) admitting diagnosis; (iii) results of all consultative evaluations of the patient and findings by clinical and other staff involved in the care of the patient; (iv) documentation of all complications, hospital acquired infections, and unfavorable reactions to drugs and anesthesia; (v) properly executed consent forms for procedures and treatments; (vi) all practitioners' diagnostic and therapeutic orders, nursing documentation and care plans, reports of treatment, medication records, radiology, and laboratory reports, vital signs and other information necessary to monitor the patient's condition; (vii) discharge summary with outcome of hospitalization, disposition of case and provisions for follow-up care; and (viii) final diagnosis.
Earlier this month, for example, while getting records for a birth injury case, I first got the run-around. §17935(e)(1), and its implementing regulations, 45 CFR 164.524(c)(4)(i), we are requesting, in an electronic format , a complete copy of the patient’s medical records from [insert date] to [insert date]. The HITECH Act and its regulations do not allow you to bill for paper copies when an electronic copy has been requested.
The health system sent me a certification from one of their locations that they had no records on the child even though I had specifically requested records from a location, where the child had been hospitalized in the NICU for several weeks. Please be aware that the HITECH Act applies to requests by third-parties, like our law firm, just the same as it applies to requests by patients: “if requested by an individual, a covered entity must transmit the copy of protected health information directly to another person designated by the individual.” Federal Register January 25, 2013 Vol 78 No. The records should include, if applicable, their Hospital admission face sheet; Discharge summary; Admission history and physical; Progress notes; Orders; Consultation; Radiology reports; Lab values; Graphic vital signs; Anesthesia record; Operative reports and notes; Pathology reports; Recovery room; Nurses notes; Medication records; Outpatient records; Emergency room records; Special diagnostic tests; and Fetal strips. I will not hesitate to file a complaint with the Department of Health & Human Services (HHS) if you violate the law by improperly applying the paper copies rate for electronic records.
(c) Authentication of medical records, record entries and medical orders.
(1) Upon completion of ordering or providing or evaluating patient care services, each such action shall be recorded and promptly entered in the patient medical record.
(2) Written signatures, or initials and electronic signatures or computer generated signature codes shall be acceptable as authentication when utilized in accordance with hospital policy.
(3) Each electronic or computer entry, order or authentication shall be recorded in the medical record as to date, time, category of practitioner, mode of transmission and point of origin.
(5) The hospital shall have a system of coding and indexing medical records.
The system shall allow for timely retrieval by diagnosis and procedure, in order to support quality assurance studies.
Hardly a day goes by without a letter from my office either requesting medical records or paying for them. It’s perhaps the most common thread among all my cases: the vast majority of my clients have been physically injured in one way or another, and at a bare minimum, I need the records from their doctors and hospitals to show the diagnoses they have and the treatment they have received.