January 2004

Who owns patient records?

by Timothy J. Feuling

As I've discussed many times before, proper record keeping is a vital key to safeguarding a chiropractic practice against successful lawsuits. Those records can show to the court that you educated the patient on the true purpose of chiropractic, and followed the practice guidelines of your peer group.

But even perfect records won't do you a bit of good if you don't have them in your possession when a lawsuit is filed!

That's why it is absolutely essential that you NEVER give patients or their representatives the original records. This has to be an inviolable policy of your office. Under NO circumstances should any patient records be permitted to leave your office.

This includes everything in the patient's file, including personal history and business office information, x‑rays, laboratory reports, SOAP notes, results from instrumentation (i.e., surface EMG, computerized muscle testing, etc.), notations in the appointment book, terms of acceptance forms, insurance forms -- EVERYTHING.

It has been amply settled in U.S. law that, while patients have the right to obtain the information contained in your records, they do not have the right to the records themselves.

Often, patients will request their records when they are moving or switching to another chiropractor. Or they say they need them for insurance purposes. However, even in such seemingly "innocent" situations, your office staff should be instructed never to give away original patient records.

Each state has specific rules governing the right of patients to obtain their health care records. In California, for instance, health care providers must permit patients to inspect their medical records during business hours within five working days after receiving a written request from the patient. Patients can be required to pay "reasonable clerical costs" associated with locating the records and making the records available for inspection. The law even specifies how much the health care provider may charge per page for copies of the records.

Check with your licensing board for the specific rules in your state, and write an office policy which covers patient requests for records. Make sure the policy statement is very specific, detailed, and written down.

When a patient requests his or her records, have the patient sign and date an authorization to release the records, specifying exactly which records are requested. Keep this form in the patient's files and advise him or her to return on a specific date to pick up the copies, or obtain an address to which they should be mailed. Make a note in the patient's file as to which records were requested and to whom and when they were sent.

If a patient demands to have the records released immediately, be prepared to show the patient a copy of the state law and your office policy. Don't be swayed! Some attorneys actually coach their clients on how to request records from a chiropractor and how to convince staff members to break the rule about releasing original material. No matter how much you might wish to oblige a patient, keep steadfast in this rule.

(Timothy J. Feuling is president of Chiropractic Benefit Services (CBS) and vice president of the World Chiropractic Alliance. He assists doctors in maximizing their practices through the proper choice of insurance and related services. Doctors may contact him with questions, comments, and requests for insurance quotes at 2950 N. Dobson Rd. Ste. 1, Chandler, AZ 85224, by phone at 800‑883‑0412 or by e‑mail: feuling@cbsmalpractice.com).