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METHODIST MEDICAL CENTER OF OAK RIDGE
PATIENT RIGHTS: ACCESS TO MEDICAL RECORD
Tag No.: A0148
Based on facility policy review, complaint reference, medical record review, and interview the facility failed to ensure patient rights were maintained when a request for medical records was denied for 1 patient (Patient #1) of 4 patients reviewed.
The findings include:
Review of a facility policy titled "Patient's Rights and Responsibilities" dated 1/1993, showed "...The patient has the right...To access, request amendment to and obtain information of disclosures of medical records in a timely manner..."
Patient #1 was admitted to the facility on 6/23/2021 with diagnoses including Overdose, Abdominal Pain, and Bradycardia.
Review of the medical record showed a Certificate of Need [a legal document used in the involuntary commitment process for individuals posing an immediate substantial likelihood of serious harm] dated 6/23/2021, was completed for Patient #1.
In reference to a complaint dated 6/1/2022, a request was made by Patient #1 on 6/25/2021 to the Patient Advocate for medical records to be obtained. Patient #1 was informed by the Patient Advocate that she was unable to access the medical records, as the Certificate of Need had meant that [Patient #1] was "...legally involuntarily committed and, also, legally incompetent..."
During an interview on 9/21/2022 at 12:02 PM, the Consumer Relations Coordinator (CRC), (Patient Advocate) confirmed Patient #1 had requested assistance to obtain her medical records. The CRC stated she went to Medical Records with the request and was informed that Patient #1 "...could not access records at that time since she had been committed against her will..." This information was then relayed to Patient #1 and a copy of the medical record was not provided.
During an interview on 9/22/2022 at 2:47 PM, the Manager of Continuous Quality Improvement and Regulatory Compliance confirmed Patient #1's denial to access of the medical record was based on incorrect information. She confirmed a patient's access to their medical record was a patient right, and Patient #1's rights had not been maintained.