The suture line on your scalp will fade, but your medical records are lasting evidence of your hospital stay – and you have the right to receive copies of those records, within 30 days of making the request.
The Privacy Rule of the federal Health Insurance Portability and Accountability Act entitles all patients to have access to their medical records. Even so, you can encounter pushback. "It still happens too frequently, that people ask for records and are told HIPAA doesn’t allow it – and that’s so not true. In fact, the opposite is true: You have the right to receive your records," says Deven McGraw, a partner at the law firm Manatt, Phelps & Phillips in Washington, D.C., and an expert in health privacy.
It's not an idle request. Patients need their medical information for their own records and to share with health providers. Up-to-date hospital records can help avoid duplication of medical tests and procedures, and can also help patients get a better understanding of their health care costs, McGraw says.
"You wouldn’t try to manage your finances without having a copy of your bank records," she says. "You need to have a copy of your health records to manage your health."
[Read: The Era of Electronic Medical Records.]
How to Ask
The first step is to fill out and sign an authorization form, says Anne Tegen, director of the Health Information Management department at Children's Hospitals and Clinics of Minnesota. "We also ask for a picture ID because while we want to provide the information to people who need to have it, we have to protect confidentiality," Tegen says. "We verify the identity, and then we get to process the request."
If you call instead of coming in person, her department will accept your mailed-in authorization, but only after validating your signature by checking it against those they already have on file.
While parents have the right to their children's medical records, access does not extend to parents who have lost all legal custody, stepparents who aren’t the legal guardians or grandparents, Tegen says.
Unless they have direct, signed authorization from the patient, spouses will not be given access to his or her medical records.
[Read: Should I Take My Child to the Hospital?]
Make Sure to Ask For...
Some pieces of information are more valuable to patients than others, Tegen says. Key documents include:
- The initial history and physical examination
- Consultation reports from specialists such as cardiologists or neurologists
- Operative reports
- Significant test results, such as echocardiograms or MRIs
- Current medication list
- Discharge summary
[Read: 11 Items to Pack in Your Hospital Bag .]
What You Don't Get to See
A few exceptions exist to information rights. Patients are not permitted access to psychotherapy notes, and health providers can also withhold information if they think it could endanger the physical safety of the patient or another person.
McGraw says that exception "is intended to be invoked in the rare circumstances that there might be harm. Not just, 'I’m not going to give this to you because you can’t handle the truth.'"
[Read: How to Survive Your Hospital Stay.]
Potential for TMI
"The medical record from a long hospitalization can be thousands of pages, and that’s not uncommon," Tegen says. "What we try to do in health information management is to guide the parent, or the patient depending on their age, to what they really need."
A lot of data can build up, especially for patients who were in intensive care, she says, and you probably don’t need every nurse’s note, vital sign or lab result.
Hospitals can charge as much as 75 cents a page for paper copies of your medical record. Pricing structures vary, Tegen says, and you should have that conversation when you make the request. "Some hospitals have a kind of standard packet – say 10 pages or less – that’s no cost, or it’s a minimal cost," she says. "But when you go beyond that, they’ll start charging whatever’s allowed by law in their state."
Regardless of whether they request their records, all hospital patients should walk out of the hospital with a summary of their stay, including all their medications and instructions for follow-up care, at no charge, Tegen notes.
[Read: How to Describe Medical Symptoms to Your Doctors.]
Setting the Record Straight
"[Patients] are allowed to get their records in any form or format they request,” McGraw says. “So if you want it sent to your Gmail account, or you want it mailed to you in the mail, the hospitals are supposed to honor that, as long as they can physically do it."
HIPAA gives you the right to request an amendment if you notice an error in a medical record, such as an incorrect medication or allergy. In cases like these, the clinician who made the original documentation often makes the change.
However, "in circumstances where there’s sort of a genuine disagreement about whether you’re right or they’re right, you can’t make a hospital change their medical record," McGraw says. Whether accepted or denied, the correction request itself becomes part of the patient's record.
[Read: Does Your Doctor Feel More Like a Medical Clerk?]
Permanent Records?
In some cases, you can ask for hospital records dating back several decades, and the health information management department will diligently track them down.
Printing from the electronic record now used by most hospitals is easy, Tegen says. "But say you were a pediatric patient 30 years ago – that information, if the hospital still has it, will either be on paper, in a storeroom someplace or it will be on microfilm."
Don't assume that hospitals will retain all – or any – of your records forever.
"In Minnesota, the key documents are retained permanently," Tegen says. But they might only be kept for seven to 10 years in other states, and the time frame is even shorter for X-ray films. "So if you’re looking for something from 30 years ago," she says, "you may not be able to find it."
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