Records requests

[hbananas]

I want to work in medical records when I grow up.  They are never there, and apparantly, they don't ever have to answer the phone or return voice mails.  I called my PCP's office to get copies of the few things that have been done since she first sent me to the neuro.  They have a good excuse.  Their calls were being routed straight to voice mail, and I filled out a form and got the job going.  I'm lucky, her office is 2 blocks from my house.

I called the neurologist's office this morning and followed the menu prompts to request my records.  Again, I left a voice mail that wasn't answered all day.  I think I'll fax them over the weekend.  Right now my question is just "What do I need to fill out to have you send me records?"

My question for my forum friends is this:  I am switching to a new neurologist. I am short a few of the things that my old neuro has, so I want them sent to me, and I'll make copies before taking to the new neuro.  If I ask for my whole record, will that also include the stuff my PCP sent to them when the ball got rolling?  I don't want to ask her office to start from scratch again, and all that lab work is very important.

I guess it is a good thing I started asking for things a month and a half before my appointment, since there will be some mailing back and forth involved.  Besides, it gives me something to do while I wait.  Thanks, all.
Holly

[Sunnytoday]

haha.. that would make me laugh to... some doctors offices are trained to be very quiet in the records area... they are sometimes small and do not have much space so they are next to other professionals who are also trying to complete tedious jobs... or they are in an office full of clerks who are ALL answering phones and requests... it can become quite hectic and lead to lowered voices that way not everyone is yelling over each other!

I love sharing all the stuff I learned in class this year, not many actually need it, so being useful is great! When our bills from the hospital and doctor came in, I actually can now know why I'm being billed for what services, and why it says what it does with the code and description, and truth be said, half of the time I disagree! :)

I'd be glad to pull together something on Requesting Records, the glitches involved, and how get your information in the smoothest way possible. Someone let me know if that would actually be helpful and if you'd help me. :)

Have a blessed day...
~Sunnytoday~

[hbananas]

Wow, that's useful information.  Do I smell a Health Page?
These were doctors' offices, and I got through to both promptly the next day I called.  Of course, I was courteous.  Today the lady at my PCP's office answered in a barely audible whisper.  I said "I'm sorry you have laryngitis or have been taken hostage."  I got a whispered laugh out of that one.  She faxed me a form and told me to just ask for everything between two dates to get what I need.

[Sunnytoday]

oh, and that part about not always being there, wonder what state that's in??? Grin! Where I worked in the records dept. it was humming all the time.... and the clerks (me then) staffed the area from 7 am to 9 pm and worked holidays and week-ends. The coders (me soon hopefully) were lucky and had a regular work schedule. The phones ring non-stop in a hospital records dept with requests, so tread lightly and be very courteous, I've been yelled at, and lied to, and hung up on by requestors during my time as a clerk before I finished school for my Associates degree.
~Sunnytoday~

[Sunnytoday]

Holly,
I suppose I'll let the cat out of the bag... I'm an Health Information Technician... soon to be RHIT.. and work in medical records.

I can do all of the routine jobs, but am actually specialized as a coder, I put codes to diagnosis and procedures through an computerized encoder by enterpreting the records and doc's writing and lab work, etc. I don't handle the billing, so don't yell at me for that. (smile) I do however, have a lot of info jammed in my head concerning the laws about records and anything pertaining to the legal-ness of releasing all or parts of them, and about anything that happens in the record dept. itself and is written in the record, SO, if question come up like this I'm happy to answer.

Ok, you're right they will only send you what they've completed at their facility. This is usually protocol, not a rule. It can be bent.

Also, FOR ALL FORUM MEMBERS... when you are requesting records... be sure to sign, date, and place the EXACT description of what you are requesting on the authorization for release form for your doctor's office or for you copies for yourself.  (example : Please, copy ALL labs, test, and nurses notes front and back... or Please, copy EVERY sheet of paper in the record) This is mandatory, and will help to ensure that you will get what you need --------This will just help, we are human to and we use copying services and can not control their every move.

Also, if you are requesting copies for a certain doc. and you know their fax, you can often have them request exactly what you need (it may take a follow-up call or two) and it be free, as a hospital or facilty will not charge a doctor who is requesting a record but will always charge a patient. Sorry, I don't like it either.

A rule we had drilled in our head in school is this "the record is the property of the facilty but the information contained in it is the property of the patient." If this is understood properly, you will be able to happily handle Release of Information folks without getting upset... they can't hand you a copy of your record without following a hundred audit checks, and you are entitled to the information that is contained within as long as it falls within this boundry, and this boundry... etc. Grin. And last but not least, there is that wonderful boss who has put in place the rule that when requests come in, on Discharge summaries go out UNLESS otherwise specified... which is why you do not get exactly what you need on the first try.

I'm always here, if you have any HIPAA questions, want to grill me on why this or that was coded a certain way on your bill or what a code means....  and as far as a medical record job, it isn't as dreamy as some think..... and yet I LOVE IT!!
~Sunnytoday~

[hbananas]

Darn.  I wish I'd heard from the neuro before I went to my PCP.  The neuro will only send me things they had done, nothing they got from the PCP.  So now I have to go back and ask her to dig up all the blood work and such leading up to the referral to the neurologist.  Minor glitch.  Just a little aggravating.
Holly

[shoshin]

Good luck! I don't know how you ever know if you got everything. What they send seems to vary so you probably better ask.

The last records form I filled out had a place for the dates wanted and also checkboxes for types of records.

However, after three attempts and paying for various pages that they sent more than once or that I have no idea why I would want (forms I had filled out myself, something that said the correct procedures were followed during my spinal tap, etc.), I finally had to get the neuro to print out the SSEP and spinal tap results. The records office denied having any such things even after I told them the names and dates of the test results I wanted.

If you discover the great secret of getting records smoothly, let us all know.

sho

[Lulu54]

Holly,
Can I be your assistant in this dream job?  :-)

You should be able to get a copy of your whole file but it probably won't come to you that way at first.  

When I was recently gathering my records helpful people were trying to decide what I really needed .I then had to go back and ask for specific thingsthat I knew I hadn't gotten - and this is from an office that I have good relationships with.

Be well,
Laura