Q. Do patients get access to their own records?

A. Yes. You need to allow patients to copy their records or you may copy their records for them.

Q. Do patients get total access to their records?

A. Patients get total access except

1. psychotherapy notes
2. information for civil, criminal, or administrative proceedings.
3. information released may be restricted for fear of patient self-harm.
4. patient access to their records does require that they sign a form stating that they have asked you to release your records to them.

Q. Are there any special access rules?

A. You need a written request as noted above for the patient to inspect their records. You either should allow them to review the original or allow them to copy the record at their choice. The patient may request a summary and you may prepare summary, at a reasonable fee. You also can make reasonable charges for copying or postage if you need to mail out the patient’s records.

Q. Can patients amend their records?

A. Yes, as discussed above. Patients may request an amendment, which you do not need to comply with. However, we have the following warning. If you have a patient inspecting his or her own chart in the office, specifically instruct your employees not to interpret your handwriting. They may give patient information that you did not intend with a somewhat illegible note. Therefore, we recommend that if you do not write legibly, you should improve your handwriting now or begin to print notes in patient records now in order to avoid confusion that may arise in the future as a result of a patient or government agency personnel misinterpreting your notes. We also recommend, as we noted above, that you do not leave the patient alone with their records to make sure that they do not amend the patient record unbeknownst to you.

Q. What is "minimum necessary" information for employees?

A. Unfortunately, the “minimum necessary” standard is not clearly defined. It is not an absolute standard, but a flexible one that needs to be applied in the light of common sense and the particular circumstances and operations of your practice. Generally, the minimum necessary information is the amount of PHI that it is reasonably necessary to use or disclose to accomplish the purpose of the use or disclosure. If we do find a clearer definition, we will provide that for you. You should be aware, however, that although the minimum necessary standard is otherwise generally applicable to uses and disclosures of PHI that you may make, it does NOT apply to disclosures to or requests by a health care provider for treatment purposes, to disclosures to the individual who is the subject of the PHI, to uses or disclosures for which you have obtained written authorization, to disclosures necessary for HIPAA compliance, to disclosures to HHS that the Privacy Rule requires for enforcement purposes, or to any other information uses or disclosures that are required by any other law.

Q. Can I leave laboratory reports on a patient's answering machine?

A. This is allowed. We recommend that in the event of abnormal tests, you ask the patient to call you back to discuss the test results.

Q. Can I confirm appointments on a patient’s answering machine?

A. This is OK and is covered under the incidental disclosure rules. You must still be careful, however, to only give the minimum necessary amount of protected information in your message.

Q. Can I disclose PHI to family members?

A. The Privacy Rule allows necessary disclosures to family members who will be involved in the patient’s care, as long as the patient is informed in advance, is given an opportunity to object, and does not do so. In some other circumstances, HIPAA allows you to make “reasonable inferences of the patient’s best interest” to allow this disclosure without authorization from the patient. Otherwise, you need a signed authorization form.

 

NEXT>>