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Based on review of documentation, review of the medical request form and interviews, the hospital failed to ensure that the patient had the right to access information contained in his clinical record within a reasonable time frame. The hospital failed to ensure that the patient was not frustrated in his legitimate efforts to gain access to his own medical record and did not actively seek to meet the request as quickly as its record keeping system permitted.


Findings included:


Background information:

Interview with the Patient Advocate on 5/26/10 at 1:20 pm indicated there was a meeting held on 4/6/10 with the Intensive Care Unit [ICU] Nurse Manager, Patient Advocate, the Patient and the Patient's support persons. In this meeting, several issues the Patient presented regarding dissatisfaction with care provided were addressed. During this meeting, the Patient made a request for a copy of the entire medical record and the Patient Advocate obtained the form to request the medical record for the Patient to fill out.

Review of the medical record indicated the Patient filled out the Hospital form to request a copy of the entire medical record on 4/22/10.



1) Review of the medical record request form dated 4/22/10 request indicated the Patient checked off each and every box on the form that included both documents and privileged or specifically protected information. The form had an open space titled, "other" and in that space was written: "entire chart" and "48 pages" along with initials that were illegible. The form did not contain an option for "entire" medical record. However, the form did contain a Section G which was titled: "I understand and agree that: My questions about this authorization form have been answered"

2) After the Patient was discharged, a telephone call was received on 5/19/10 from the Patient to report the copy of the entire medical record was still not received as requested. The medical records department reported that an abstract of the medical record was sent to the Patient. The Patient Advocate said the medical records department correspondence staff person contacted the Patient on 5/20/10 to clarify which sections of the medical record the Patient wanted and to notify the Patient of the costs and obtain approval for the expense. A second copy of the medical record request form was noted to have a stapled slip of paper as an addendum indicating the Patient wanted the complete record and agreed to pay for 538 pages.

3) Review of documentation indicated the entire medical record was mailed on 5/24/10. As of 5/26/10, the Patient had still not received the medical record in the mail.

4) The Patient had not received a copy of the entire medical record as requested in a timely manner. The Patient requested a copy of the entire medical record on 4/22/10 and it was still not received as of 5/26/10, over 1 month after the request was made.

5) On 4/22/10, the Patient checked off each and every medical record topic area box on the form, which clearly provides the impression that the entire medical record is being requested. However, according to interview with the Patient Advocate and the Risk Manager, if the first box which states "Medical Records Abstract (e.g. History & Physical, Operative Reports, Test Reports and Discharge Summary)" is checked off, the medical records correspondence only mails the abstract of the medical record which is the condensed summary of the entire inpatient stay. The medical records correspondence department disregards the remainder of checked-off requested boxes, even though the person has indicated they are requesting copies.

6) If all boxes on the medical record request form are checked as requested, the medical correspondence department should not make an assumption that the abstract alone meets the person requesting the record information needs, absent clarification or approval from that person.

7) The form lacked information regarding costs for copying and mailing costs to avoid additional delay or frustration in receiving requested information. The medical record request process did not provide information regarding anticipated number of pages so that persons can anticipate the expenses - many medical records can reach 500 pages or more with ICU stays or lengthy inpatient stays. Providing information regarding copying and mailing costs upfront can prevent delays in providing requested materials.