Whether you are in a solo practice or a multidisciplinary clinic at some point you will be asked to share your records with other professionals, courts, or researchers.
This can be intimidating if you aren't prepared for the request. This article will help guide you through how to make this process easy.
In Canada health record privacy is regulated provincially. Each province has their own privacy commissioner that can help you through any privacy situation you run into. For now here's a simple procedure for you to follow to help you stay compliant with health records and privacy legislation. Less work for you in the future if you are organized and ready now!
1. Keep your records up to date: it's easy to forget to complete a chart when things get really busy. But the longer you leave it the harder it is to remember the sessions details. Choose your charting style - SOAP, SBAR, narrative, etc... And stick to it. Make sure your charts are organized by dates and that you have easy access to the chart when you need to pull it up. If you're sick of your paper charts and you are running out of storage space for them (since some records have to be stored for decades!) consider switching to EHIS.
2. Receiving the record request: the request can be stored in the relevant client's chart. Make sure you record the date it was received in the chart as well. Then get ready to process the request in a timely manner.
3. Validate the request: make sure the requesting party had a legal right to have the chart information. Just because they are a lawyer doesn't mean they get instant access. Usually, they require a subpoena to have the authority to access the file. The client usually has to give permission for the chart to be accessed. Written permission is always the best! Use the download button next to this post to get a release of information form to use.
4. Complete the request: make sure you have the right clients chart and all the information between the dates that have been requested. Now, don't be tempted to alter the records in any way. Especially if they are being subpoenaed. It's best to make two copies of what is being sent. Keep one copy with the chart as a new entry of what was sent and the date that you sent it. For research, requests make sure this process is followed each time you send ongoing information.
Use these simple steps to create your own process for your business. Remember to review the process with your coworkers or employees so that everyone is on the same page. These requests are usually time sensitive so having a process in place makes everything quicker and easier.
If you have any questions, let me know below!
Reference: AHIM (2018) Management Practices for the Release of Information. http://bok.ahima.org/doc?oid=85544#.WpwcTMtrk0M
Please note that this blogs information is meant to be a helpful guide and does not replace legal or professional advice.