HospitalInspections.org

Based on document review and interview, the facility failed to follow their policy related to a request for the release of medical records for 1 of 10 medical records reviewed. (Client #1)

Findings include:

1. Facility policy titled "Designated Record Set" last approved 1/26/16 indicated the following: "...Policy...will maintain a set of records known as the Designated Record Set, for each...client...This is the set of records which clients have a right to request, copy or amend...Designated Record Set -Reference Guide...Inpatient Paper Chart...: [included, but was not limited to]...Orders and Progress Notes...Outpatient Paper Chart...: [included, but was not limited to]...Progress Notes...Electronic Clinical Record...:[included but was not limited to]...Clinical Service Documentation...Archived Documentation...(Scanned Paper Documents...): [included but was not limited to]...Progress Notes..."

2. A review of Client #1's medical record on 7/17/19 beginning at 2:30 p.m. indicated the following:

a) The client had an "AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION" signed by the client and witness on 9/14/18, that indicated the following: ...1) I am authorizing this release (check all that apply): [check mark in box] Verbal communication [check mark in box] Copies of records...2) For the purpose (check all that apply): ...[check mark in box] Client's request...4) ...may release...(select Core Care Documents package or individual documents): ...[check mark in box] Physician/Prescriber Treatment Notes...6) (Optional) Expiration: My authorization is valid for two years from the date signed...7) I have read this information and been offered a copy. I am the client, or I am authorized to act on behalf of the client to authorize the use or disclosure of this information...STAFF USE ONLY (Required)...Indicate immediate action [check mark in box] File only [check mark in box] Release documents listed above..."

b) A case management note with a service date of 9/14/18 at 9:00 a.m. to 9:30 a.m., indicated the following:
"...Data: ROI [Release of Information] for self to get physicians notes. Talked with records. [Client #1] asked the Cf [Care Facilitator] would call and talk with the records keeper to find out what [he/she] needs to get [his/her] records from [Facility #1]. Also had [him/her] sign a release of information to gather [his/her] records from [Facility #1]...Interventions: Called the records dept. [department] with [Client #1] to see what [he/she] would need to do to get [his/her] records from here. Filled out an ROI for [Client #1] to gather doctors notes for [him/her]..."

c) The client's "Release of Information History" indicated a lack of release of information to the client for the years of 2018 or 2019.

3. During an interview on 7/17/19 at 3:05 p.m., A2 (Director of Information Technology Services) and A6 (Manager of Clinical Records) verified that a release for medical record copies should be completed no more than 30 days from the time of the request.

4. During an interview on 7/17/19 at 3:09 p.m., A5 (Director of Support Services) verified that if a request for copies of medical records comes in then the request is generally completed. A5 verified Client #1 was the exception.

5. During an interview on 7/17/19 at 4:48 p.m., A2 and A4 (Release of Information Staff) verified that Client #1 did not receive a copy of his/her medical record as requested on 9/14/18 and/or documentation of a reason as to why the request was not completed.