How to Create a Release of Records Process at Your Medical Practice
Who takes care of releasing medical records at your practice? If it is a staff member, are they specifically trained for this responsibility?
Posted in Risk Management on Thursday, December 15, 2016
As a healthcare provider, you no doubt receive a number of requests for release of medical records. Lately, when inquiring of a process for proper release of records, what I have heard during onsite risk assessments is “Oh a staff person takes care of sending off the records.”
The question which then arises is – are the employees responsible for releasing medical records specifically trained for this responsibility?
Releasing records is not a task to be taken lightly
The release of records requires that staff members work diligently to adhere to federal and state guidelines, as well as HIPAA regulations – all of which must be considered. These guidelines and regulations present a good reason for ongoing staff training and having a release of records process.
There is one more very important reason to have a policy for releasing records – malpractice insurance coverage.
Three situations of late bring to light the malpractice insurance need for a records release policy. The circumstances involved non-clinical staff, in three different practices and states, who released medical records without advising the providers of the requests.
Unfortunately, the providers were later named in claims resulting from those released records. The providers did not have knowledge of the potential claims when they completed their applications for coverage. So, when the claims did subsequently arise, it appeared as if the providers were not being truthful on the applications which could have voided their malpractice coverage for these instances as well as the policies entirely.
Starting a release of records process at your medical practice
It is good to have a policy with corresponding procedures addressing the release of records, especially when the request arrives from an attorney.
Having a limited number of individuals responsible for releasing records is a good first step in this process so consistency can be maintained.
Some additional areas of consideration for release of records policies and procedures include:
- Patient authorizations – what is acceptable in various situations (such as minors, emancipated minors and deceased patients)
- Court orders
- Federal/state specific protections (such as mental/drug/HIV conditions)
- When the provider and administrator should be notified of requests
- Priority requests and time frames for release
- Maintaining a log to indicate:
- The patient’s name
- Who requested the information (e.g. patient, parent, guardian, attorney)
- When the request was received
- What information was released
- Who released the information
- When information was released and by what means
- Fees charged
Not only should your practice have this process in place, but your staff members should also be annually trained on release of records policies.
To view a sample general medical records release form, which can be modified for your office, visit our online Forms Library.