Name of the Procedure:

Medical Records Copying Fee, per Page
Common Names: Medical Record Duplication, Chart Copy Fee

Summary

This procedure involves the copying of medical records from a patient's chart or electronic health record. Each page of the records requested incurs a fee. It is a standardized process used to provide patients or authorized parties with their medical information.

Purpose

The purpose of this procedure is to provide patients, healthcare providers, legal representatives, or other authorized entities access to a patient's medical records. This can be necessary for continuing care, transferring to a new healthcare provider, legal purposes, or personal use. The goal is to ensure the patient's medical history and treatment details are accurately and securely shared per their request.

Indications

• Patients changing or seeking a second opinion from healthcare providers.
• Legal proceedings requiring medical documentation.
• Patients who wish to maintain their own copies of their medical history for personal reference.
• Coordination of care among multiple healthcare providers.

Preparation

• Obtain and complete a records release form, which may require the patient’s signature or legal authorization.
• Provide identification or proof of authorized access.
• Specify the range or type of documents needed, e.g., test results, clinical notes.

Procedure Description

1. Request Submission: Patient or authorized party submits a formal request and any necessary authorization forms.
2. Verification: Healthcare facility verifies the authorization and patient's identity.
3. Location: Specific records are located within the electronic health record or paper files.
4. Duplication: Each page is either scanned or photocopied.
5. Compilation: Copied pages are compiled, potentially organized with an index or cover sheet.
6. Delivery: Copies are sent to the requester via mail, fax, electronic transfer, or in person.

Duration

• The process typically takes anywhere from a few days to a couple of weeks, depending on the volume of records and the facility's procedures.

Setting

• Administrative offices of hospitals, outpatient clinics, or individual healthcare providers.

Personnel

• Medical records clerks, administrative assistants, or Health Information Management (HIM) professionals.

Risks and Complications

• Common Risks: Sensitive information potentially being sent to unauthorized individuals.
• Rare Risks: Misplacement or loss of records during the duplication process.
• Management: Regular audits and secure handling protocols to prevent unauthorized access and loss.

Benefits

• Access: Quick and organized access to vital medical information.
• Continuity of Care: Facilitates smoother transitions between healthcare providers.
• Legal: Supports legal processes with necessary medical documentation.
• Benefits are usually realized immediately upon receiving the requested records.

Recovery

• No physical recovery needed for the patient.
• Patients should securely store or further process their received copies according to their needs.

Alternatives

• Electronic Health Records Access: Some healthcare providers offer online portals where patients can directly access their records at no additional cost.
• Summary Reports: Instead of full copies, request for a summarized version of pertinent medical information.
• Benefits: Faster and at times more comprehensive access through electronic portals, though availability varies by provider.

Patient Experience

• During Procedure: Simple administrative request, no physical discomfort involved.
• Post-procedure: Ensure proper understanding and security of received medical copies. Any discrepancies or additional needs should be communicated back to the healthcare provider.
• Pain Management: Not applicable. Comfort is maintained as there are no physical aspects to this administrative procedure.