Confidentiality of Patient Medical Record
Patient confidentiality will be maintained regarding every
aspect of care in this facility and patient information and
to comply in every manner with State and Federal law
pertaining to the release of information from the patient
medical record. Any employee who unlawfully discloses
patient information will be subject to disciplinary
action--up to and including termination of employment.
Confidential patient information includes, but is not limited
to patient clinical information, clinical protocols and
There are three types of allowed records releases:
1. Requests TO this organization to forward medical records
out of the office to other providers or to an insurance
company or attorney.
2. Requests FROM this organization to receive medical
records from another provider of care.
3. Requests for this organization to forward medical records
out of the office to miscellaneous entities.
Requests for release of sensitive information relating to
psychiatric treatment, alcohol/substance abuse treatment, and
records documenting the patient's HIV status must separately
specify authorization for release of medical information.
Requests for release of medical records will be fulfilled
within five days of receipt. Requests unable to be fulfilled
(i.e., chart missing, request not properly executed, etc.)
will be returned to the requestor as soon as possible.
1. All requests to release copies of patient charts must be
in writing and contain the following information:
A. Designation of the name of person, company or agency
to whom the information is being released.
B. Specification of the period of time to be covered.
C. Signature of the patient or his/her legally
The following protocol will be followed:
A. The subject chart is pulled or
if EMR accessed electronically
and given to the appropriate Staff member with the
request attached to the front of the chart.
B. The Staff member reviews the chart and designates
the content to be released.
C. Designated personnel photocopy or
if EMR print
D. Date of release is documented onto the original
release form which is then photocopied. The
original is inserted or scanned into the patient
chart and becomes a permanent part of that patient's
medical record; the photocopy is attached to the
front of the photocopied packet for return to the
E. The photocopied packet is forwarded to the requestor.
In special circumstances, a patient may hand-carry a records
release request to the office and wait while records are
copied for hand-carrying to another provider/requestor.
Logistical limitations make this a necessarily rare
2. Requests for release of medical records may be generated
by this organization, e.g., in order to obtain records of
patients new to the practice or to obtain records of
patients who have received care external to the practice.
The following procedure is followed when a request for
release of patient information to another party (health
care provider, attorney, etc.) is generated by this
A. The release request is signed by the patient
B. The date that the request is generated is noted on
the front of the release form.
C. The release is photocopied with the original
forwarded to the party in possession of the records
and the photocopy maintained in a 'tickler' binder.
D. Upon receipt of the requested records, the 'tickler'
copy is removed from the binder and discarded.
E. On a moving 30-day basis, tickler copies are checked
and re-sent as necessary to stimulate a response.
3. Patients desiring to exercise their right of correction
or amendment of the personal health information
contained within the medical record, may petition for
such correction using the appropriate forms. The
process for such petition is noted on the form.
4. Occasionally, a patient may request that medical records
be forwarded out of the office to miscellaneous
entities; or, other entities with a legitimate concern
may make a request; examples are noted below:
A. Non-staff persons who make inquiries concerning
patients must present proper authorization from the
patient. The Medical Director will extend all
reasonable courtesy, keeping the interests of all
parties in perspective.
B. All requests for information by any agent of the
press or media shall be referred to the Medical
Director or designee.
C. Requests by patients for information about their own
records shall be referred to the attending Staff
member in charge of their care. Patients wishing
copies of their personal medical record must sign
the release or forward a signed release.
D. Police inquiries shall be referred to the Medical
Director or designee.
E. Requests for information regarding a deceased
patient shall be referred to the attending
Under no circumstances shall the fact a patient is
deceased be released by any staff member. Requests
for any information about a coroner's case shall be
referred to the Office of the Chief Medical Examiner.
F. The Medical Director, with the written approvals
of the Governing Body and the Medical Executive
Committee, will permit use of patient
medical records for research purposes only under
stringent regulations, including IRB review, as
Should it be discovered that there has been a breach to any
individual's private health care information, all
requirements regarding the breach and individual notification
will be followed.
5. Charts are intermittently evaluated for possible removal
to storage; the following circumstances may trigger such
A. Charts of deceased patients.
B. Patients who have moved from the area and
transferred copies of their records to a new
C. Patients who have transferred to another staff
member for on-going care.
See the 'RELEASE OF MEDICAL RECORD' forms and the relevant
Approved By Governing Board