HospitalInspections.org

Based on a review of policy and procedures related to release of medical record information, review of information related to release of medical records, and interview with staff, the hospital failed to ensure ensure requested medical records were released according to regulation and per hospital policy.

The findings include:

1. A review of policy HIM.I.18 entitled Release of Medical information: The policy indicated medical records may be reviewed, or compiles furnish, only upon receipt of authorization signed and dated by the patient, guardian, if a minor, conservator if conservator if mentally incompetent, next of kin, administrator or executor, in case of death...the policy goes on to document the fees for release of the record. The policy related to access of individuals to PHI (personnel protective information) HIM.I.03. Also indicated the information must be supplied within 30 days of the request.... If the requested information is not on the organization's premises, provide the patient with the information within 60 days of request.

2. It was confirmed with the medical record staff. She said Patient #2's spouse requested copies of the patient's medical record on 8/1/18 when the patient was discharged. The medical record staff said she has not provided this information as yet to the power of attorney. She said was out of the office at a seminar and it did not get done. Her assistant was out of the office on workman's comp and she was not able to do this. The medical record department provided 2 lists of patients whose records had been provided from 8/1/18 through the current time. None of the lists showed documentation of when the copies had been requested, and when the information had been totally completed for Patient #2. None of the record requests showed Patient #2's power of attorney had requested this information. There was no documentation showing the record requests were made to the hospital.