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RUSH UNIVERSITY MEDICAL CENTER
PATIENT RIGHTS: ACCESS TO MEDICAL RECORD
Tag No.: A0148
Based on document review and interview, it was determined for 1 of 1 (Pt #1) clinical record reviewed with a request for release of medical records, the Hospital failed to ensure the record was released as required. This potentially affects all patients requesting the release of health information.
Findings include:
1. Hospital policy entitled, "Disclosure of Patient Health Information," (approval date 7/29/16) required, "...Personal Representatives- Rush will treat a personal representative of a patient as having the same authority as the patient to the extent it is reasonable to do so ...Responsibility and Procedure ...5. If additional time to respond to a patient's request is needed, contact the patient as to the reason(s) for the delay and the date by which the request will be completed ....Within 30 days of receiving the authorization. Rush must inform the patient the request has been ...If the protected health information is not maintained or accessible on premises, Rush has 60 days to act on the request. If Rush cannot act on the patient's request within the aforementioned time frames, Rush may have a one-time extension to respond ..."
2. Hospital policy entitled, "Health Information Management Department - HIPPA Privacy," (updated 8/14) required, "...Permissible Uses or Disclosures With Written Authorization ...4.1..1.6 When the patient is deceased, the following hierarchy applies ...Adult child of the deceased ..."
3. On 8/23/16 at approximately 1:30 PM the Assistant Director of Health Information (E #2) presented an "Authorization Relative Certification - Decease," dated 5/17/16 and signed by Pt #1's daughter requesting release of inpatient and outpatient/clinic records from 12/15/15 to 3/22/16 (day before Pt #1's expiration). Documentation indicated that outpatient visits from 12/30 15 and 1/7/16 were released. Pt #1's inpatient record from 2/29/26 to 3/23/16 was not released.
4. E #2 stated during an interview at approximately 1:45 PM that the copying service used was having difficulty and was backlogged. E #2 also stated that the Pt #1's daughter was not notified of the delay and reason as required.