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Patient Medical Records: Understanding Your Rights 

Patient rights to access their health information, be it from their doctor’s office or their health plan, is guaranteed under the Heath Insurance Portability and Accountability Act (HIPAA) Privacy Rule. Passed in 1996, HIPAA gives individuals the right to see and receive copies of their health records upon request. However, this path is often riddled with barriers that frustrate patients and caregivers. With this article, we hope to provide some clarity around accessing your medical records, revising your medical records, and sharing your medical records.

accessing your medical records

Implementing provisions from the 21st Century Cures Act (Cures Act), federal rules now require healthcare providers to provide patients access to all the health information in their electronic medical records quickly and without charge. Your doctor’s office must share the following:

  • consultation notes
  • discharge summary notes
  • history & physical
  • imaging narratives
  • laboratory report narratives
  • pathology report narratives
  • procedure notes
  • progress notes

Psychotherapy notes (notes taken by a mental health professional when talking to a patient) are a notable exception. A patient may not access psychotherapy notes. 

filing a complaint when the system fails

The Cures Act bolstered HIPAA to ease the process of accessing your medical records from your doctor’s office or hospital. If you are experiencing “information blocking”—meaning you are not able to easily find or access your electronic medical records or notes from clinic visits—you can lodge an online complaint with the federal department of Health Information Technology using this form.

Correcting Your Medical Records

A medical record is a legal document. While information in the medical record cannot be erased, it can be corrected by adding a clarifying note. 

According to the code of federal regulations:

  • A patient has the right to request changes to their protected health information or record with a covered entity (health care provider, health plan, or healthcare clearing house) as long as the information is maintained in the designated record set
    • The request may need to be submitted in writing along with a reason supporting the amendment
  • A covered entity could refuse to make the requested changes if they believe that the protected health information:
    • Was not created by the covered entity
    • Is not a part of the designated record set
    • Would not be available for inspection
    • Is accurate as is
  • The covered entity is expected to act within 60 days of the request being received:
    • If approved, take the required actions per the request 
    • when denied, provide the patient with the written denial
  • If unable to act within that time, the covered entity may extend the time for action to not more than 30 days 
  • The covered entity must ensure that the amendment reaches the persons or business associates, as requested by the individual, within a reasonable time

Here’s an example of how Patients Rising Concierge assisted a client who had reached out about correcting an error in their medical record. If you need assistance with access to your medical records, or for any other healthcare issues, you can reach out to us at Patients Rising Concierge.

Surabhi Dangi Garamella

Surabhi Dangi-Garimella, Ph.D. is a biologist with academic research experience, who brings her skills and knowledge to the health care communications world. She provides writing and strategic support to non-profit groups via her consultancy, SDG AdvoHealth, LLC.

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