HospitalInspections.org

Based on interview and policy review, it was determined the facility failed to honor patient's right to access to their own record for 1 (#1) of 11 sampled patients.



Findings include:


1. During interview on 12/1/11 at approximately 12:30 p.m., the Director of Health Information Management stated that the mother of patient #1 had requested access to the medical record and was denied because she had no legal documentation that she was the guardian for the patient. Review of the medical revealed that the patient was an adult patient with Down's Syndrome, per the "Discharge Diagnoses Summary." A 9/3/2011 progress note of 0715 stated, "Pt. is asphasic, makes incomprehensible sounds." The mother provided the medical history information for the patient and had signed all consents. The mother provides 24/7 care for the patient in her home. This was documented by social services. The facility's policy "Access to Inspect of Copy Protected Health Information" #3.2, effective 4/03 requires that the patient's representative provides the patient's name, address and date of birth and or social security number. It further states that representative verifies relationship with the patient in order to gain access to the patient's record. This information was present in the medical record and supplied by the mother. The Risk Manager was interviewed on 12/1/11 at approximately 4:30 p.m. She confirmed that the mother should have been allowed access to the medical record.