Responding to Patient Records Requests? Follow This Expert Advice

Posted on 5 Feb, 2016 |comments_icon 4|By Chris Boucher
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Be as accommodating as you can with patients who want to access their info.

Patients requesting access to their medical records should be a top priority for any practice that wants to stay compliant and trustworthy.

The basics: A patient has every legal right to her medical records, and if you don’t provide access ASAP, not only could you run afoul of the law — you could erode patient trust in the process. 

Maria V. Ciletti, RN, works as a medical administrator in Niles, Ohio, and is also a member of the American Medical Writers Association. We checked in with her to see how to best respond to patient requests for medical records.

Reply to Requests with Trio of Options

When a patient requests to review her medical records, these are the best choices for the practice, according to Ciletti:

  1. Send medical records to the patient through an online patient portal, if your practice offers this option.
  2. Copy the patient’s record, and let her come into the office and review it when staff “are available to answer questions,” or
  3. Copy the requested records and hand-deliver or mail them to the patient.

Best bet: Try to be flexible; offer the patient all three options to access her medical records, if you have the capabilities to do so.

Read also: Responding to Patient Records Requests? Follow This Expert Advice

Make Time for Patients Who Dispute Record

When a patient accesses her medical record, there is always the chance that she will challenge the contents of it. Should a

patient challenge your records, you have to be ready to respond with a practice representative that knows the patient’s record and is qualified to speak on the practice’s behalf.

Patients with concerns about their medical records should feel welcome to discuss the issue with the practice, Ciletti says. “We will sit down with them and go over their concerns,” she says. Often, these meetings result in greater patient understanding, according to Ciletti.

“Sometimes [the misunderstanding] is language the patient doesn’t understand. Sometimes [the record] was dictated wrong,” she says.

If the practice committed the error, however, a meeting with the patient can also help restore patient confidence. If the practice has made the mistake in the patient record, a face-to-face meeting with the patient is the best way to handle the situation. This will show the patient that you are aware of, and concerned about, the situation. A face-to-face meeting about the misstep will help the patient feel that you will resolve the situation quickly, which you should most certainly do.

(For more information on all topics related to practice management, check out Practice Management Alert at www.codinginstitute.com/specialties/practice-management)

Author

Chris Boucher


Chris Boucher has nearly 10 years of experience writing various newsletters and other products for The Coding Institute. His blog will cover several areas of coding and compliance, including CPT® coding, modifiers, HIPAA compliance and ICD-10 coding.

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