The Patient Who Wants to See the Note
A patient calls and asks for a copy of his full medical record, including the physician's progress notes from his last three visits. He says he is switching doctors and wants to review everything before his new appointment in five days. The practice uses an EHR, and the front desk clerk tells you the practice 'usually just sends the visit summaries' and that the full notes 'take too long to pull.' The patient becomes frustrated and says, 'It's my record, I have a right to it.' The physician is in with patients and cannot be interrupted. The practice's release-of-information form requires a 10-business-day turnaround, but the patient wants the records in five days. You are the MA handling the request.
1. Is the patient correct that he has a right to his records? What should you tell him, and what should you actually send?
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Yes - the patient is substantially correct. Patients generally have a legal right to access their medical records, and the practice should provide the records he requested, not just visit summaries. Sending only summaries when full records were requested is not responsive.
What to tell him: acknowledge his right, explain the practice's process and timeline, and be honest about the five-day request. Do not promise records in five days if the practice's process is 10 business days; instead, tell him you will submit the request today and give him the realistic timeline. If the practice can accommodate the five-day request, say so only after confirming with whoever pulls records.
What to send: the records he asked for - progress notes and the other components of his record - subject to the practice's process for handling any sensitive-content review that the physician may need to do. Do not unilaterally substitute summaries for the requested notes.
2. The clerk wants to send only summaries 'to save time.' How do you respond, and what documentation should accompany the release?
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Explain to the clerk that the request is for the full record, and substituting summaries risks a complaint and is not what the patient asked for. The time-saving argument does not override the patient's request.
Documentation to accompany the release:
- A signed, dated authorization (or documentation of the patient's written request) identifying what was requested.
- The date the request was received and the date records were sent.
- Exactly what was sent (e.g., 'progress notes 1/12, 2/03, 2/24; lab results; immunization record').
- Who processed it and the method of delivery.
- Any fee charged, if the practice charges one, consistent with applicable rules.
If any portion is withheld, document the specific reason and who made that decision. Keep a copy of the log entry with the release.