by William Malamon, ABC
The responsibility of managing medical records can provoke anxiety in any physician’s office. Medical records are confidential and personal documents, and the rules that govern them are often complex and confusing. Physician practices encounter many unique situations involving medical records. This article will help dispel the common and pervasive myths that surround the retention, release, and management of patient health information.
Myth 1: Physicians must always supply patients with copies of their medical records free of charge.
Truth: How much a physician can charge for copies of medical records is a commonly asked question. According to the Texas Medical Board (TMB) Rules, “The physician responding to a request for such information shall be entitled to receive a reasonable, cost-based fee for providing the requested information. A reasonable fee shall be a charge of no more than $25 for the first twenty pages and $.50 per page for every copy thereafter.”
The physician is entitled to this fee before releasing the information, unless requested by a licensed Texas health care provider or a physician for purposes of emergency or acute medical care. If a request for information is received other than for emergency or acute medical care, the physician can retain the copies until payment is received. However, if the physician does not receive payment with a proper request—within 10 calendar days after receiving the request (if not for an emergency or acute medical care)—the physician must notify the requesting party in writing of the need for payment, and keep a copy of the letter in the patient’s medical record.
In an emergency situation, physicians should not withhold copies of the medical records until payment is made. If the request involves a claim for disability benefits, the records must be provided free of charge. (source)
Myth 2: Physicians can deny access to a patient’s medical record because of a past due account.
Truth: Copies of a patient’s medical records cannot be withheld because of outstanding medical bills. According to the TMB, “Medical and/or billing records requested pursuant to a proper request for release may not be withheld from the patient, the patient’s authorized agent, or the patient’s designated recipient for such records based on a past due account for medical care or treatment previously rendered to the patient.”
Myth 3: Medical records must be kept under “lock and key.”
Truth: While medical records do not need to be locked away, they should be stored in an area that is inaccessible to patients. Medical records should not be stored in hallways, waiting rooms, exam rooms, or in any area where unauthorized individuals could access the records.
Myth 4: A physician is not required to release a minor’s medical record to the minor’s parent if the minor was treated for a condition that does not require parental consent, such as pregnancy.
Truth: Provisions in the Texas Family Code Section 32.003 allow for a minor to consent to his or her own treatment if the minor:
- is on active duty with armed forces of the United States;
- is 16 years of age or older; resides separately and apart from his or her parents, managing conservator or guardian; and manages his or her own financial affairs, regardless of the source of income;
- consents to the diagnosis and treatment of any infectious, contagious, or communicable disease that is required to be reported;
- is unmarried and pregnant, and consents to hospital, medical or surgical care, other than abortion, related to her pregnancy;
- consents to examination and treatment for chemical addiction, chemical dependency, or any other condition directly related to chemical use; and/or
- consents to counseling or counseling in conjunction with treatment by a physician, psychologist, counselor, or social worker if the treatment and/or counseling is for sexual abuse, physical abuse, suicide prevention, chemical addiction, dependency or abuse.
Share your thoughts on medical records myths. Leave us your comments!