a doctor on a computer, medical records, electronic medical records, interns, visit notes

Patients own their medical records. They may find it difficult or expensive to access that information, however.

In past decades, doctors and hospitals stored patient information on paper forms. If a person wanted access to her data, she had to get a nurse or clerical person to find the files and copy them, page by page. That was expensive, time-consuming and often frustrating for everyone involved.

Electronic Medical Records:

This situation was supposed to change in the era of electronic medical records. Now 97 percent of hospitals and 83 percent of physicians rely on electronic records for their patients. That means that your medical records are readily accessible to your health professionals. In theory, you should be able to access all the key information in your records. In reality, that is rare. There are only a few hospitals or clinics that provide patients “OpeNotes.”

Places like Stanford Health Care, Beth Israel Deaconess Medical Center and Geisinger Health System have expanded OpenNotes. This encourages physicians to share detailed health information directly with patients in their medical records.

Why OpenNotes Are Important!

Many people can now see a limited amount of information through what are called patient portals. For example, “MyChart,” a system found on many electronic health records, allows patients to see messages from health care providers, lab results, appointment schedules on a calendar, a brief review by the provider, a list of medications and billing information.

What is not included is a detailed provider assessment and analysis of the visit. These are often referred to as “clinic notes.” They are the nuts and bolts of any medical record. These are the notes a physician, nurse practitioner or PA puts in the medical chart during and/or after your visit.

They allow for a far more thorough understanding of what is going on with your case. You will see what the diagnosis is, what the treatment recommendations are and much more. They give patients greater understanding and control of their care. They also help reduce the likelihood of medical errors because a patient has a vested interest in making sure everything is accurate. If a mistake is made in the medical record the OpenNotes system should allow the patient to communicate corrections.

A systematic review of patient access to medical records (Acta Clinica Belgica, Jan. 6, 2017) noted:

“Only a minority of patients spontaneously request access to their medical file, in contrast to frequent awareness of this patient right and the fact that patients in general have a positive view on open visit notes. The majority of those who have actually consulted their file are positive about this experience. Access to personal files improves adequacy and efficiency of communication between physician and patient, in turn facilitating decision-making and self-management. Increased documentation through patient involvement and feedback on the medical file reduces medical errors, in turn increasing satisfaction and quality of care. Information improvement through personal medical file accessibility increased reassurance and a sense of involvement and responsibility.

CONCLUSION:

From the patient perspective medical record accessibility contributes to co-management of personal health care.”

How Much Will You Have to Pay to Get Your Medical Records?

A federal guidance last year limited copying fees. It suggested a flat fee of no more than $6.50 for digital health records. But patients may still have trouble getting copies of their records.

Sadly, health professionals often charge per-page copying fees allowed by state law. These were designed for paper records and can be as much as 10 cents a page; more for scanned images. Health systems may also charge additional search and retrieval fees. Kentucky is the only state in the country that requires the initial copy of a patient’s records be provided for free.

Such state charges could add up to hundreds of dollars for a medium-sized medical record. Texas and Minnesota have the highest maximum allowable fees in the country: $53.60 for a 15-page record in Texas and $218.70 for 150 pages in Minnesota. A few keystrokes could print out an entire medical record or transfer it to a thumb drive in minutes.

How Much Should a Copy Cost?

The authors point out that electronic medical records should allow for easy, inexpensive reproduction of patients’ data. Now all that is needed is the institutional will to do so.

JAMA Internal Medicine, online Jan. 30, 2017

We firmly believe that everyone should have access to their medical records. You might enjoy this story, with a music video on “Gimme My DAM Data,” from e-Patient Dave about his experience. (DAM means Data About Me: my medical records.) The Society for Participatory Medicine has been working on the problem of helping patients get access to their own medical records. Let us know how you have gotten a copy of your own record. Was it worthwhile? Please share your experience below.

You may also find our book, Top Screwups Doctors Make and How to Avoid Them of interest. It reveals why medical errors are a leading cause of death in the United States and why getting access to your medical records could be so important in preventing health care harm.

Top Screwups Doctors Make and How to Avoid Them

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  1. Kenneth
    Reply

    I am a patient at a busy VA hospital. All my care is provided at this location from labs, radiology, primary Docs and specialists. All my medical records are accessible to me online. I have total access & can print out whatever I like from this system. I make it a habit to read all my notes. I have found mistakes and innacuarcies on my chart. I have brought it to the Doctors attention and corrections were made.

    Now that my physicians are aware of me reading all my notes they seem to take more care in what they write. It’s a very important part of my treatment and it helps both the busy physicians and me. The VA has done a great job in giving us access to all records of our healthcare. Of course you have to do the leg work but it’s a great way to keep everyone up to date.

  2. G
    Reply

    My husband and I make it a practice to get a printout with diagnosis, progress notes, meds, orders, etc and a copy of the most recent lab or diagnostic report, AT EACH PHYSICIAN’S VISIT. We don’t leave the office without this. We then hole punch and place in a binder for reference after scanning them. Later these are down loaded to a USB drive which we can take with us on trips and use for storage. Once the record has been scanned to an electronic device, then the paper copy can be destroyed as you choose. I wish it was such that we could take the USB drive to office visit and download directly, but our docs don’t have that capability, so we devised our own system and so far it works.

  3. Lynn
    illinois
    Reply

    Regarding the ownership of the records, they may belong to the medical facility as they pay for the storage, software, etc. But it is regarding my body and the visit was paid for by me (my insurance or a combination of the two). There are many patients that have no interest in their records but I am not one of them. I want autonomy over the decisions made about my body and therefore I need as much information as possible. Any treatment is my decision and I have to live, or die, with the consequences.

    I have known a few people to have the incorrect lab tests put into their records. It happens both were discovered for unique reasons. I cannot help but wonder how often this happens and how to avoid this error? When you go to “My Chart” you cannot see the name that is associated with the results. In other words the whole test is not scanned in the record. You are assuming they are yours. I find this scary.

    It means you should get the original for any abnormal result.
    Any thoughts from others regarding this?

  4. Sue G.
    Sebastian florida
    Reply

    My husband changed doctors due to Dr. wanting him to have MRI at imagine place that he has an interest in. He is claustrophobic and requested to have an MRI at the hospital which is partly open. He was told at the one the doctor said or nothing. He signed a form on Feb. 11 to send his records to the new doctor did not send records I called three times still did not send records.

    On the 23rd, had appointment with new doctor no records received. I called on 23rd and told office staff that the hippa law says he is entitled to his records said they would send records never sent . On the 25th called and said my husband will pick up his records and was asked to come after 1pm picked up records and took to new doctor. Included in his records were 3 pages of another patients records alot of patient history I shredded the personal records.

  5. OldandRetired
    florida
    Reply

    I agree that the patient owns the records. When you pay the doctor , lab, hospital, etc, you are paying for services and you are entitled to know what you are paying for. Would you take you car to a repair shop and settle for the mechanic just saying “I fixed the noise in your engine ” and handing you a bill that only says repaired problem? Wouldn,t you also like an itemized bill showing what parts are replaced and why? In the medical field, like it or not, there are many who charge for service not rendered or not needed.

    I have already quit doctors how have taken tests totally unrelated to my complaint. And, before you doctors complain, my family is very deep into medicine from being RN’s to my oldest son who is a Surg. Gen in the military.

  6. Gerry
    SC
    Reply

    I just completed a work shop on Diabetes by a Nutritionist who also has further studies and a certificate to teach and this one was free, paid for my Medicare. It was the most informative information that I have ever received in regards to diabetes.

    She informed us that we are entitled to a printout of our report when we visit our dr. We are fortunate enough to have a good dr. but he rattles off that everything is fine and looking good, but never I get the numbers. At my next visit I am going to ask for this report and thereafter.

  7. Melinda
    Reply

    Last Spring, I asked for copies of my records from a wrist surgery, and was told I had to pay $25 for the first 10 pages, and then $2/page for additional pages. In addition, they would not mail me the copies….I had to drive 40 miles to pick them up, even though I offered to send then an SASE.

    It is typical of this doctor to gouge his patients in every way he can. Another indicator that he isn’t the best is that when I read his notes (written after he’d performed the surgery and seen me for at least 15 office visits), he referred to me as “Nancy” in his notes. I don’t expect a doctor to remember me on the street, but if he has reviewed previous notes just before seeing me (which is customary), he SHOULD be able to use my correct name when he is writing that day’s notes.

  8. Lynda M
    Washington
    Reply

    What if you can’t remember what Dr.s you went to years ago? How can you get that info?

  9. Lyn
    WA State
    Reply

    There are chart notes that Drs. and administrations deny exist, at least at the big clinic I use. They let you see the “My Chart” notes, but I found that there are other notes that often don’t accurately reflect a patients demeanor, questions, or responses to a patients request that they aren’t willing to give to patients. The MD has a tag that only he/she can show to the computer to access the Drs. chart notes. They do not want you to read their comments about a patients visit.

  10. Sandy
    Reply

    I think dental records should also be accessible. When you you want to change dentists, you should not have to face that dentist and ask for them. That is what I had to do when I changed, so I opted to not get them. The dentist that I had gone to for 25 years, I found out, was not being honest with me. After thousands of dollars, so much had to be redone. He is still in business.

  11. Clo6
    Houston
    Reply

    My intuition kicked in after going to a primary care doctor for a fairly long time and I decided to change doctors at which time I requested copies of everything. I discovered the doctor had not been honest with me about my tests results. Now I always request copies of any tests that are done.

  12. Joan K
    Reply

    About 2 years ago my Drs medical group went online, I can now access everything from my computer at home. I mean everything, every test I get even blood tests are on there. What the Dr discussed with me is there also. I have a password just as you do with your bank account or any other important information. I go to an orthopedic Dr also and the group he is with automatically sends you the information.

    I go to the Dr and when I get home 15 minutes later it is already there. You can see the information from past visits also. I love this feature. I go to it to see what my blood test factors are and it tells you what is his or low. Then I can go on to Google and look up whatever I think is important. I know everything befor the Drs office calls to tell me. Of course if it is important his nurse will call the next day.

    Technology has come a long way. I believe, if it’s possible to have all your Drs in the same medical group.

  13. jim
    sioux falls, sd
    Reply

    it is not true that patients own their medical records. the provider that produced the work to create the record owns that record. Most patients under state law have a right to a copy of their records, for a fee that covers the cost of reproducing the record.

    • Joe Graedon
      Reply

      Jim,

      It appears that this issue is a lot more complicated than we or you imagined. A thoughtful articled titled “Doctor or Patient? Who Owns Medical Records?” was published on January 18, 2016 on the American Academy of Family Physicians website. It was written by Kyle Jones, MD. Here is what Dr. Jones says:

      “Different states have different laws regarding ownership. Only one state, New Hampshire, explicitly gives ownership to patients, whereas most states have no law delineating custody of records.”

      He goes on to describe OpenNotes and why doctors were initially nervous about the concept.

      “But even many skeptical physicians have been pleasantly surprised by the results of allowing full access. In one published pilot project, the 105 primary care physicians who participated all wanted to continue its use by the end of the experiment. This pilot also showed significantly improved patient satisfaction and education, and it also was thought to contribute significantly to improved patient safety.”

      BOTTOM LINE:

      In some states the hospital or clinic “own” the medical records. In other states there is no clear ownership. As for the fee, the federal government has ruled that it should be $6.50 total, but most states charge by the page. In the era of electronic medical records that seems unfair, since transfer to a patient’s thumb drive costs nothing and takes less than a minute for most data.

    • Donna
      Buffalo, New York
      Reply

      FYI – In my state ~ New York ~ I have always been charged 75 cents per page! I think that’s highway robbery.

      Right now, I am in the process of getting my 90 year old mother’s post op records. She’s in an assisted living facility and she does not have capacity for her health care needs. As a Nurse Practitioner, I have concerns about her recent hospital stay and why certain medications were changed following her discharge. Getting her records has proven to be a huge problem, even though I am her Health care proxy.

  14. Sal
    CA
    Reply

    Timely article… I have a 35 year history with a group of orthopedic surgeons that started with 5 doctors and over time shrank to one. As you might guess, many, many surgeries over the years. My last big surgery was 2010 and since then I have moved about 300 miles away.

    When my new primary care doctor wanted to see my surgical history, I began the totally unsuccessful search for my records. Seems my surgeon had passed away sometime after my 2010 surgery and his office closed. I had no idea and I have tried everything I can think of to find my records with no success. I even contacted both the medical society in the city he practiced as well as the medical society for the state – no help at all.

    The only document I could finally access was from the hospital regarding some limited background on the last surgery. I must take responsibility for some of my frustration because I never really gave it much thought until it was too late but somehow I feel that a better system should be in place to allow patient access no matter when that might be needed.

  15. KW
    CA
    Reply

    Thanks for this article. Is there a law or guidelines on how long medical professionals must keep patient records? I paid a CA doctor $20 to be told they didn’t keep records longer than 3 years and regardless they had nothing on file.

  16. Jack
    Florida
    Reply

    Asked my long time medical provider, Health First Medical Group, for a copy of all my records, as I was tired of being unable to fill in forms about when I had what done. They told me it would take a day. Next day I went to medical records, and picked up a Manila Envelope with a stack of paper records about an inch thick, giving me what I asked for. No charge.

  17. Mary
    Reply

    I also would like to know what other readers say about this obtaining your own medical copy.

  18. Mary
    Reply

    Thank you for the wonderful advice of how to obtain a person’s medical records. I figured that Texas was high in price in obtaining a medical record. Since, I live in Texas. Two of my Doctor’s that I go too are doing this. It does help a person to keep up with what is going on.

    I’ll call up my PCP and see if they are going to be doing this procedure. I hope they answer will be yes. But, to be honest with all of you, I think the answer will be no. Just have that feeling. But it is worth a try. Keep up the good work at People’s Pharmacy. I do enjoy reading all of the articles and have learned some things.

  19. Em
    NC
    Reply

    My comment concerns those Patient Portals: I started to create an account at one Dr, but read the disclaimer that once I agree to the terms of creating an account, the office is no longer bound by HIPAA laws to protect the confidentiality of the medical information. So if the system or account is hacked, the Dr holds no responsibility. I have yet utilize any patient portal as I am unwilling to give up HIPAA protection.

  20. Jennifer
    Roanoke, VA
    Reply

    This issue has been a real frustration for me. Doctors are unwilling to release lab results via Patient Portals until they have reviewed them themselves but are often way behind because they are over scheduled with appointments. I either have to make an appointment to find out results, which costs me around $100, or request medical records which takes about a week or two. Additionally, I have to fill out paperwork to mail or fax when I should just be able to log into the patient portal and click a few buttons.

  21. Marian
    Reply

    Organizations that make medical records available to patients should be publicly applauded. My experience with Langone in NYC has been exemplary. Test results immediately posted; doctor’s notes on reading my MRI and Ct scans equally fully shared.
    Bravo.

  22. Linda
    Madison, WI
    Reply

    If it’s so expensive to have paper copies, why not get them electronically? If email is considered too risky, could a person provide a thumb drive to be downloaded? Of course it would have to be done by a health care professional because of privacy issues. Wouldn’t it?

    I wonder how private our personal files are after talking with a “customer care” woman in my HMO who told me they depend on the integrity of employees to not access information they’re not supposed to access. That was not reassuring to me.

    Notes made by doctors, physician assistants, certified nurses, medical students–everyone who is authorized to treat you and/or take notes about you that go into a file–should be accessible to you as a patient. I have seen errors in my medical history on MyChart, errors made in transcription from my handwritten answers to the electronic form entered by–who??

    I doubt they require highly paid professionals to do data entry. So, I truly doubt there’s a lot of privacy or security in our medical files. All the more reason to be able to see them–and to know who all in health care industry has access to them.

  23. suziQ
    Minnesota
    Reply

    I asked for and received my medical records including x-rays. It just took asking for them. The x-rays were sent by snail mail. I probably have 100 pages I printed out. They are only available for a given length of time. That’s why I printed them. There was no charge .

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