Are Patients Allowed to See Everything That Is on Their Medical Chart?

by | Published on Jun 20, 2016 | Medical Record Review

The HIPAA (Health Insurance Portability and Accountability Act) gives U.S. patients the right to access their medical records and control who else has access to the information. Attorneys handling claims associated with health insurance, personal injury, and medical malpractice will have to place a request for the patient’s healthcare records for a medical records review. The request is to be made either by the patient or his/her representative attorney. Health insurers also require patient healthcare data for medical claims review to ensure that provider billings are reasonable, accurate and appropriate for services that have been actually provided.

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Can Patients See Everything That Is on Their Medical Chart?

When people are allowed easy access to their health information, it empowers them to be more in control of decisions as regards their health and well-being. It enables them to monitor any chronic conditions they may have, follow treatment plans correctly, track progress in disease management or wellness programs, and find and correct any errors they find in their medical records.

However, a host of legal issues exist that prevents people from viewing everything in their medical records. This is because of concerns related to disputes with patients about the content in the records, about the extent of information that can be revealed to patients who are minors or mental patients, and the fear of malpractice litigation.

According to a study by researchers at the University of Washington that appeared in the Annals of Internal Medicine, providers have certain specific areas of concern.

  • Issues related to content that patients may find difficult to understand: Providers fear that patients may misunderstand content or find errors in entries that could lead to legal action. Doctors are also worried about how patients will gather their own medical data and enter it into their files in addition to the concern regarding its legal status.
  • In the case of minors, parents usually have control over the children’s medical records. Physicians can prevent parents from accessing the records if there is suspicion of abuse or if they believe that parental involvement is not in the best interest of a child. Laws vary in this regard and liability concerns may have an impact on the decisions made by doctors.
  • Typically, HIPAA prevents patients from accessing their psychotherapy notes in certain circumstances. These records are kept separate from the patient’s medical and billing records. The provider cannot make disclosures about psychotherapy notes of a patient without his/her authorization. However, some state laws are more flexible and allow broader access to the medical notes. Providing easy access to mental health records may cause more harm than good to the patient. Providers are divided in their opinion, with some thinking it extremely dangerous, while some others feel that reviewing their medical records may make patients more proactive about their health.

The New Rule and Possible Unrestricted Access

However, patients may now have unrestricted access to their medical records with the new rules that took effect in October 2022 under the 21st Century Cures Act. It provides patients full access to their medical records in a digital format. Treating physicians or providers are required to make the medical records available digitally, upon patient request. Moreover, the process must be free, timely, and secure. Thus, patients can have easy access to their healthcare information without the exorbitant charges associated with printed pages.

There may still be roadblocks on the way. Though the new rules provide patients access to their doctors’ notes, medical images and even genetic data and other protected information, healthcare providers and other medical data custodians may still withhold information, quoting exceptions. This is because the enforcement under the new rules is still somewhat vague or unclear. There are concerns regarding the protocols for sharing the digital records, verifying the rights of access, and what it actually means to give patients all their data. The question is whether patients must even be given each and every observed value in an ICU, every log entry, and every email.

Experts hope that this new rule will provide patients more power over their own health and pave the way toward better care. When patients have full access to their records, it provides other benefits as well. They can opt to add a new specialist, switch providers, and even share information with researchers who may need certain healthcare data. Importantly, it would also ease the process of legal medical records review, enabling attorneys to prepare their cases more quickly and efficiently. Given the huge volume of information to manage, many organizations and advocacy groups are already assisting patients in organizing and managing their medical records.

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