Medical records

[heartfelt77]

When you ask your doctors or hospital for your records how do you really know if they are giving you all of your records?  And what if they have a problem giving your records to you?  Tks misty.

[LindaTX]

Where we live we have to go through Medical Records to request copies of any records.  Lab copies are usually given in the Dr.'s office.  Anything else you have to pay for.  At the hospital they will let you, supervised of course, come in and actually look at your records and you can sit there and take all the notes you want....free of charge. This can be very time-consuming. They are all very protective, almost paranoid when it comes to YOUR records.  I think they fear lawsuits and malpractice claims....sometimes with good reason.  Oh, and you would be surprised at what you see written in your records.

[doublevision1]

Much depends on the jurisdiction in which you live.  All provinces in Canada have privacy legislation in place which governs the collection, use, disclosure and destruction of your personal information, including personal health information.  I am most familiar with the Health Information Act of Alberta, in the province in which I currently live.  

Health care providers are mandated by law to provide access to and, if requested, copies of one's health records.  This includes ALL of one's health records: everything from blood tests and MRI results to GPs notes to ER files and specialists' reports.  Health care providers are permitted to charge a nominal fee to cover the cost of copies and administrative time required, but no more.

Typically in any privacy related legislation there will be exclusions to the disclosure requirement, mainly around whether the disclosure of such information could reasonably be expected to put the recipient or another party in harm's way.  

In my experience, all physicians have provided copies of my records including CDs of my MRIs, at no charge and immediately upon verbal request.   They do have the right to withold my information until such time as a written request is provided, but none have ever asked me to do so.  Most think it's great that I keep track and one said he wished more patients took as much interest in their own health.  

If one suspects there is information that is being witheld despite providing a formal, written request, the next step is to appeal to the provincial Privacy Commissioner or similar entity explaining what you are looking for.  An inquiry is opened and should it be discovered that information was witheld that is not subject to an excusion clause, the holder of that information is subject to financial penalty.

Sorry, can't speak to the situation in the U.S. or anywhere else; hopefully similar rights and protections are in place.

[caregiver222]

That is an interesting question. Decades ago, physicians and hospitals routinely refused to provide all test results and evaluations, as well as x-rays. They were taken to court, and in general, will release MOST records. Such decisions are termed stare decisis decisions. But you need to request them in writing, registered mail, and be prepared to wait. They are also reluctant to release ER records. Years ago I was brutally assaulted, and when the court case came up the ER physician wrote "in a barfight"! So it pays to check on them. Fortunately there was video footage available. I was not in a bar, but a store adjacent to a bar shopping. Therein lies the beast. For example in surgery there are notes taken and they won't usually release these without what is called a subpoena duces tecum. Neither will they release psychiatric records, except to another psychiatrist, no matter how much you beg.

[beachcomber13]

You should always request a copy of test results (bloodwork, etc.) as they happen, for your own records. You can make sure those are present. And check that there is a record of each visit you have made. You can check your calendar or try to remember approximately when you were there.

I am guessing this is for the Cleveland Clinic, yes? If so, I would make sure all of the test results are there and not worry about anything else. The neuro there will do his own exam and may not care much what the other doctor thought.

I had a doctor argue with me about getting my records. Mostly she was arguing the reason that I wanted them--a referral to an MS specialist. But I held my ground and calmly continued to request them. I got my way. I am pretty sure they have to give you your records if you ask.