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CancerLynx - we prowl the net
June 3, 2002

Patient Rights to Medical Records
Roy Rada, MD, PhD


The excellent report "Your Medical Records" at http://www.cancerlynx.com/records.html and dated April 1, 2001 suggests that a polite letter to your physician should be enough to earn you a copy of your medical record (minus paying for the photocopying). The author's also note that California law requires physicians to respond to such letters positively. The suggestion is that failure of the physician to reply could be followed by contacting a patients rights group, the local medical society, the state medical board or an attorney.

We might note that since that report was written a Federal Regulation has taken hold which mandates patient access to medical records. The Regulation is called the Privacy Rule and became effective April 14, 2001 with two years till all health care providers need to comply with the Rule. The Rule emphasizes that patients have a right to a copy of their medical record whenever the patient requests it. If the patient finds the provider not complying with the request, the patient should complain to the provider's Privacy Officer (every provider is required to have a Privacy Officer) or to the Office of Civil Rights of the Department of Health and Human Services which has enforcement responsibility for the Privacy Rule.

M.J.McKeown, M.D. reports in "How to Correct Your Medical Records" at http://www.cancerlynx.com/correctrecord.html that patients should be able to write to their health care provider and initiate amendment to medical records that are inaccurate. The suggestion is that failure of the physician to reply could be followed eventually by complaining to the physician's medical society. Again we want to point to the new Privacy Rule which mandates patient opportunity to amend the medical record. If the provider does not reply within 30 days to a request to amend the record, the patient is directed to file a complaint with the provider Privacy Officer or the Office of Civil Rights of the Department of Health and Human Services.

My sympathies are at one with those expressed by the authors of the preceding two articles -- namely, that patients should know what is in their medical record and should be proactive as regards the content of the record. One of the problems with the American health care system is the relative lack of emphasis on prevention relative to the emphasis on treatment. The patient can best correct this imbalance by taking responsibility for the patient's health and the prevention of disease. For some patients this will mean having their complete medical record at home and taking responsibility for maintaining that record.

Roy Rada, MD, PhD rada@umbc.edu
(more information about the Privacy Rule can be found at many public sites, such as http://aspe.hhs.gov/admnsimp


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