Medical record release is tough, and ever-changing regulations certainly don’t make it easier. So HealthMark CEO Bart Howe put pen to paper for the Summer Edition of For the Record magazine, “Evolving Education: 5 Things to Know When Releasing Medical Records.”
There’s an old proverb that says, “Eat the elephant one bite at a time.” Medical record release is an elephant, but we have five bite-sized tips that will help further your knowledge of this mammoth topic.
According to the Association for Health Information Outsourcing Services (AHIOS), the medical record is often referred to as the “who, what, when, where, and how” of patient care. The sheer amount of data contained inside patient records is overwhelming, but if you break it down into those buckets, it feels a bit more digestible. For example:
- Who: The patient;
- What: Documents, films, graphs, imaging, etc;
- When: Dates of visits, tests, and conversations;
- Where: Provider locations, health systems, and geographical information;
- Why: Reasons for visits, symptoms, treatment discussions, and diagnoses.
Every health care facility a patient visits is required to maintain that patient’s medical records and protect them from loss, damage, alteration, or unauthorized use. Medical records can be considered legal documents and can only be released by facilities under specific circumstances.
Following are the five key things to do when releasing medical information:
- Ensure that the authorization is valid
- Understand the nuances of navigating a subpoena
- Make sure you’re maintaining an accounting of disclosures
- Know how to handle unauthorized disclosures and breaches
- Train and certify anyone who processes medical records.