Psychiatrists sometimes ask what they are obligated to provide when receiving a request for records. Often these records contain sensitive (and potentially harmful) information about the patient or others (such as spouse, parent, sibling, offspring) if disclosed as part of the fulfillment of the records request.
A request for records can present a quandary for the psychiatrist, psychologist or psychotherapist.
Note: “Medical records” hereafter will be used to encompass mental health and behavioral health information, in addition to medical data, such as results (for labs, xrays, mental assessments and personality tests), prescriptions, consults, and referrals. Likewise, from this point forward, “patient” will be construed to include the patient (for medical treatment) or the client (for psychotherapeutic treatment).
The following are issues to consider when a request is received.
Step 1: The rationale for the request
While requests can be made for a variety of reasons, usually they are made to satisfy one of three principle needs:
- The patient is moving away from the area in which you practice and wants to take the records with him/her in order to make available to the new provider a summary of care rendered while working with you.
- Another party – acting on the patient’s behalf – requires information contained in the patient’s record, such as:
- the Social Security Administration (to determine eligibility for disability benefits)
- Worker’s Compensation (to assess or verify the emotional and mental impact of injuries sustained on the job)
- insurance carriers, managed care entities or a TPA (third party administrator) for reimbursement
- other healthcare providers or healthcare systems (such as hospital, clinic or rehabilitation facility) to provide ancillary or specialized care to your patient
- An attorney representing the patient, the patient’s guardian or some other special interest
Step 2: Making the proper request for release of information
In any of the above-mentioned instances, the request should:
- be in writing
- include a HIPAA-compliant authorization signed by the patient or the patient’s legal guardian
- “Legal guardian” may be a parent – in those cases where the patient is a minor – or a court-appointed guardian for those individuals deemed incompetent (for minor children 14 years and older, signatures of both the minor patient and the parent/guardian are recommended).
- The authorization should be time-specific (e.g., from 01-01-2004 through 12-31-2006).
- Unless otherwise noted, the authorization should be regarded as “in effect” for one year from the date of execution, but not longer.
- And finally, there should be a caveat to the effect that the authorization is revocable immediately upon receipt of a written request by the patient or the patient’s guardian to do so.
Step 3: What information to provide to satisfy the request
For the lion’s share of records request, the information that will satisfy the request includes:
- Dates of treatment (beginning date, dates of service and last date of contact, if applicable)
- A summary of the treatment, including
- the treatment plan goals
- patient adherence to that plan
- an indication as to how successful the treatment plan was in meeting treatment goals
- an explanation for how the treatment plan was revised during the treatment period and for what purpose(s)
- Likewise, if prescribing medications, a list of meds should be included, along with any labs required to monitor toxicity levels, efficacy dosages, and so on
Information that is deemed to be potentially injurious to that individual’s overall health and welfare may be withheld from certain requests for records (usually those made directly from the patient).
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