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Medical Records

  • George J. Annas

Abstract

There are about a billion visits annually in the United States to doctors’ offices, clinics, HMOs, and hospitals, and each visit either generates a new record or adds to an existing one. At the turn of the century, approximately 90 percent of all medical services were directly delivered by physicians. Today, fewer than 10 percent of all health care providers are physicians. In the typical hospital, for example, one-third or less of a patient’s record will be created by the attending physician.

Keywords

Medical Record Health Care Facility Supra Note Patient Access State Statute 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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Notes

  1. 1.
    V. Fuchs, Who Shall Live? (New York: Basic Books, 1974), at 56.Google Scholar
  2. 2.
    Privacy Protection Study Commission, Personal Privacy in an Information Society (Washington, DC: Government Printing Office, 1977), at 278.Google Scholar
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    Joint Commission on Accreditation of Healthcare Organizations, Accreditation Manual for Hospitals, 1989 ed. (Chicago: JCAH, 1988), at 95.Google Scholar
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    Goldfinger & Dineen, “Problem-Oriented Medical Records,” in Thorn et al., eds., Harrison’s Principles of Internal Medicine, 8th ed. (New York: McGraw-Hill, 1977), at 9.Google Scholar
  5. 5.
    See, e.g., “Approach to Disease,” in Harrison’s, supra note 4; and Dobson, Documenting Outpatient Medical Records, 75 Federation Bull. 323 (1988).Google Scholar
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    See, e.g., Board of Trustees of Mem. Hosp. v. Pratt, 72 Wyo. 120, 262 P.2d 682 (1953), upholding the right of a hospital to suspend the privileges of a physician who did not comply with the requirement to keep records up-to-date. And see Grayson, Incomplete Medical Records: Three Case Solutions, 8 Hospital Medical Staff (March 1979).Google Scholar
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    Accreditation Manual for Hospitals, supra note 3, at 97.Google Scholar
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    For a state-by-state listing of the current statutes and a summary of the judicial decisions on medical records, see “Medical Records,” in Health Law Center, Hospital Law Manual (Rockville, Md.: Aspen, 1988), at 78-107 (updated periodically); see also W. H. Roach, S. N. Chernoff & C. L. Esley, Medical Records and the Law (Rockville, Md.: Aspen, 1985), at 219-72; Kaiser, Patient’s Rights of Access to their own Medical Records: The Need for New Law, 24 Buffalo L. Rev. 317 (1974); and Note, Toward a Uniform Right to Medical Records: A Proposal for a Model Patient Access and Information Practices Statute, 30 UCLA L. Rev. 1349 (1983). Information on state law can be obtained from the state attorney general’s office, or by writing the American Medical Records Association, 875 N. Michigan Ave., Chicago, Ill. 60611Google Scholar
  9. 9.
    E.g., the Massachusetts regulation (243 CMR 2.06 [13]), reads in part: A licensee shall provide a patient or, upon a patient’s request, another licensee or another specifically authorized person, with the following: i. A summary, which includes all relevant data of that portion of the patient’s medical record which is in the licensee’s possession, or a copy of that portion of the patient’s entire medical record which is in the licensee’s possession. It is within the licensee’s discretion to determine whether to make available a summary or a copy of the entire medical record. ii. A copy of any previously completed report required for third party reimbursement.Google Scholar
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    Lipsitt, The Patient and the Record, 302 New Eng. J. Med. 169 (1980). And see letters to the editor, 302 New Eng. J. Med. 1483-84(1980); Roth, Woldord & Meisel, Patient Access to Records: Tonic or Toxin? 137 Am. J. Psychiatry 592 (May 1980); and Pierce v. Penman, 515 A.2d 948 (Pa. Super. Ct. 1986).Google Scholar
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    R. Burt, Taking Care of Strangers (New York: Free Press, 1979), at 113.Google Scholar
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    Golodetz, Ruess & Milhous, The Right to Know: Giving the Patient His Medical Record, 57 Arch. Phys. Med. Rehab. 78 (1976).Google Scholar
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    Stevens, Stagg & MacKay, What Happens When Hospitalized Patients See Their Own Records, 86 Annals Internal Med. 474 (1977) And see Stein et al., Patient Access to Medical Records on a Psychiat ric Inpatient Unit, 136 Am. J. Psychiatry 3 (1979); Bouchard et al., reported in “How to Reduce Patient’s Anxiety: Show Them Their Hospital Records,” Medical World News, Jan. 13, 1975, at 48; and Gill & Scott, Can Patients Benefit from Reading Copies of Their Doctor’s Letters about Them?, 293 British Med. J. 1278 (1986).Google Scholar
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    Personal Privacy, supra note 2, at 297.Google Scholar
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    Knox, “Medical Board Told Patients Should Get Access to Records,“Boston Globe, Mar. 2, 1978, at 15.Google Scholar
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    Shenkin & Warner, Giving the Patient His Medical Record: A Proposal to Improve the System, 289 New Eng. J. Med. 688 (1973). See also letters to the editor, 290 New Eng. J. Med. 287-88 (1974)Google Scholar
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    Halberstam, “The Patient’s Chart Is None of the Patient’s Business,” Modern Medicine Nov. 1, 1976, at 85–86Google Scholar
  21. 21.
    E.g., 243 CMR 2.06 (13) (d) (Massachusetts Board of Medicine Regulation). More recently it has been suggested that hospitals are making it increasingly difficult for patients and their physicians to obtain copies of records and radiographs. To help make access easier, and diminish the need for unnecessary repetition of invasive studies, deposit charges for radiographs should be eliminated, copying fees should be reduced, and requests for unabridged medical records should be honored and processed in no more than forty-eight hours from receipt “if the records [as is increasingly the case with commercial medical-record depositories] are not stored on the hospital grounds” (Kaufman, “Barriers Between Patients and Their Medical Records” [letter], 319 New Eng. J. Med. 1672 [1988]).Google Scholar
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    See, e.g., Hospital Law Mannual, supra note 8, at 16.Google Scholar
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    Id., and see supra note 8.Google Scholar
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    G. J. Annas, L. H. Glantz & B. F. Katz, The Rights of Doctors, Nurses and Allied Health Professionals (Cambridge, Mass: Ballinger 1981), at 163–64.Google Scholar
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  26. 26.
    It may take the rest of the world longer to adopt an open medical records policy. For example, it was still seen as radical for patients in New Zealand to ask to see their medical records in 1987. S. Coney, The Unfortunate Experiment (Auckland, N. Z.: Penguin, 1988), at 8. In the United States, on the other hand, there are even commercial companies to assist individuals in organizing and maintaining copies of their medical records, such as Medic Alert (1-800-ID-ALERT) and the American Academy of Pediatrics’ Medical Card (312-228-5005). Individuals are increasingly being advised to travel with a copy of the results of their latest physical examination or hospital discharge summary, and individuals with heart conditions should carry a copy of their cardiogram when they are away from home. See Sloane, “Keeping a Medical History in Hand,” New York Times, Jan. 14, 1989, at 50.Google Scholar

Copyright information

© George J. Annas and the American Civil Liberties Union 1992

Authors and Affiliations

  • George J. Annas

There are no affiliations available

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