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with Rod Moser, PA, PhD

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Friday, February 10, 2012

Who Owns your Medical Records?

By Rod Moser, PA, PhD

Medical Records

“We are really sorry, but we can’t seem to find your chart.”

We often heard this in years past, but since the advent of EMRs (Electronic Medical Records), lost charts are uncommon. Instead, we hear: “I am sorry, but the computers are down. We cannot access your files.”

Many years ago, to augment my meager teaching salary with the University, I worked part-time in the Urgent Care at a local Air Force base. Lost charts were so commonplace that the excuse was expected., and pulling charts when the patient arrived sometimes took longer than the actual visit. Much to my surprise, a large number of patients came into my office, chart in hand. Why? The simple reason was that they never returned the chart to medical records after their last visit! They would keep it so it would not get lost. While this practice may have violated a dozen Air Force regulations, I just looked the other way and was glad they had their chart. Since it was the patient’s responsibility to take it back to medical records at the end of the visit, I really didn’t care.

The real problem with this practice was lab and x-ray reports. If there was a chart that could not be found, how would these reports be posted? Medical records would have to create a temporary chart, or perhaps the reports would be lost. Twenty years ago, at this same Air Force base, the ceiling in medical records caved in from the sheer weight of stacks and stacks of unfiled lab reports, x-rays, and charts. Apparently, a disgruntled airman, anxious to get home at the end of a busy day, removed one of the ceiling panels, and when he was ready to go home, he would simply toss the files up into the ceiling space. When reports were requested, he played stupid and claimed he never saw them. The number of tests that had to be repeated was enormous. Not only were frustrations and costs involved, some of the unfiled tests were abnormal. A delay in getting results may have caused unnecessary harm or worse. I heard that he was court martialed.

I wanted to see what a former urologist wrote in his notes since he did not bother to examine me, nor did an ER doc I saw. What would they record in the notes? Thinking they may lie about doing an exam, I reviewed my records. They did not lie. They did not write anything!

I am no longer allowed to read my own medical records. I can get my lab test results and a few other reports on line if I sign up for a service, but if I “break the glass” to access my own records, all kind of alarms sound. When we had paper charts, I would freely access my records, so what is the difference? Of course, my records (nothing to hide, incidentally) could be read by anyone in the clinic. Now, anyone who tries to read my electronic chart will be quickly identified.

What would happen if patients were required to keep their own medical records and bring them to each visit, like a passport? A recent study reported in the New York Times tried it out, fostering the concept of shared medical records. While many doctors, as you might imagine, voiced skepticism about this practice, the patients loved it. Over 90% of the patients felt that they would exercise more control over their own medical care if the saw and read their notes.

On the WebMD Ear, Nose, and Throat community board, I am often astounded at the number of postings were the patient was not even told their diagnosis! There was no discussion on any rationale or even a discussion on why they were given a certain medication. These patients were left hanging. If they could read their chart, then perhaps they would have many of those answers.

Here lies a problem. I take pride in the thoroughness of my chart notes, but I have to say that many of my colleagues write lousy notes. I write my notes knowing that I am not the only one who will read them. My chart notes are my only record of the visit, and my only defense should there be an unexpected outcome. I am proud of my notes and would happily give any of my patients a copy of their progress notes, but unfortunately, I am not going to have them completed by the end of their 15-minute visit. Since we have to type our own notes (not dictated and transcribed), I must complete them between patients, over lunch, or after clinic hours. I refuse to dilute my time with a patient by typing during the visit and having a computer screen create a barrier. If a patient wants my notes, they get them. I will email it to them, drop it in an envelope, or create an after-visit summary.

A patient deserves to have full access to their medical records. They shouldn’t have to beg for them (or steal them). They should not have to pay extra to get a copy of their records. I am merely a consultant in their care. They are already paying me for the service I provide (or their insurance companies). Legally, we have to maintain accurate medical records, but there is nothing in the law that states they cannot be freely shared with the patient themselves.

Further Reading

How to Get Your Medical Records

Is it a Good Idea to Have Access to Your Doctor’s Notes?

When Your Medical Records are Wrong

Posted by: Rod Moser, PA, PhD at 4:26 pm

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