HIPAA grants individuals the right of access and the right to inspect one’s medical and health information within designated record sets maintained by HIPAA covered entities.
The right to inspect one’s medical records is not frequently discussed.
Why would someone ask to inspect their or their loved one’s medical record? What if you don’t want an actual copy of the records, but you just need to see them?
In the real world, the story is always the same.
A patient is hospitalized. The patient and their carepartner may have many questions that are unanswered about the current medical situation. The patient may be unconscious. Whether it is hospitalization due to a motor vehicle accident, a stroke, heart attack, a surgical complication, cancer treatment, COVID19, pregnancy, or a mental health condition, patients and their carepartners need access to information to make informed decisions about care.
Patients and their carepartners often wait for updates on test results, consultations, and diagnoses watching helplessly from the bedside. Doctors, nurses, clinicians, and members of the care team all refer to computer screens and smart devices for information about the patient’s medical condition. If the patient is not conscious or is unable to speak or advocate for themselves, the carepartner is often alone in their quest for the latest information.
Why isn’t it standard operating procedure to welcome patients and carepartners to pull up a seat, to view their caregiver’s screen, and welcome patients and carepartners desperate for information to follow along in real-time?
In critical care situations, there often isn’t time to formally request access and copies of all medical records. Some decisions can’t wait for days and weeks. Some decisions need to be made on the scale of hours, minutes, moments. We need to meet patients and carepartners where they are and support their right to inspect their medical records.
Sometimes patients and their carepartners need to see what the doctors and care team see to:
- be on the same page.
- participate in shared decision-making.
- process the gravity of their current situation.
- help make an unimaginable and unfathomable health situation somewhat tangible.
- fill in missing gaps in information.
- ensure nothing has been missed.
- be confident that all information thus far is correct.
- have all the information required to make a life or death decision.
The right to inspect medical records can be fundamental, especially in critical care circumstances. The rapid deterioration associated with many COVID19 cases has shown us how quickly and unexpectedly, people can become incapacitated and unable to speak and advocate for themselves. Primary carepartners play a significant role in needing to stay abreast of all of the latest information to make an informed decision about their loved one’s care. No Visitor Policies have further isolated patients and broken lines of communication between families and care teams.
We are failing patients and their carepartners in supporting their right of access to inspect their medical records. Frustrated and overwhelmed patients and primary carepartners are often heard saying the following:
“Why does everyone here know everything about my spouse/partner/parent/child/loved one, but I can’t see the same records also to be a part of the decision-making process?”
“Why isn’t anyone telling us anything?”
“I want to see what’s in my/my loved one’s chart.”
“Show me what you see on your screen.”
“Who made this discharge plan without my/our input?”
Patients and carepartners: don’t be afraid to ask to inspect and review the medical records used to guide clinical decision-making. While covered entities technically have 30 calendar days as a timeframe for providing access, many covered entities will be able to grant immediate access to electronic information thanks to health information technology. Be firm, especially when your loved one’s life depends on it.
In cases where the patient cannot advocate for themselves, carepartners should know that a covered entity may share the individual’s information with the family member or other person if the covered entity determines, based on professional judgment, that the disclosure is in the best interest of the individual.
Hospitals, healthcare delivery organizations, doctors, and practices should prioritize expediting access and the ability to inspect records, especially in critical care situations.