HospitalInspections.org

Based on review of documents and staff interview it was determined the hospital failed to maintain a procedure for release of information per policy. This failure increases the risk for information or copies of records to be released to unauthorized individuals.

Findings include:

1. The policy "Release of Information," revised June 2004, was provided for review. The policy states in part: "Release of Medical Records For Other Than Treatment, Payment or Hospital Operations, Determine the need for information and forward an authorization for release to be signed by the patient...Request for information form, if for reasons other than treatment, payment or operations, will be kept in the patient's chart."

2. An interview was conducted with the Medical Records Director at 11:23 a.m. on 5/23/16. The process for release of medical records was discussed with him. He stated patients and/or legal decision makers for patients do not sign any form for release of records, nor is any record maintained to reflect a release of records. The above hospital policy, "Release of Information," was reviewed with him.

The Director confirmed the Medical Records Department is not following policy for completing and maintaining the Request for Information Form. He stated currently there is no record of patient requests for records and/or records of what has been released to which patient. He stated the use of the Release of Information Form would be implemented immediately.