Medical Records from Lasik

[LauraK]

Has anyone else requested their medical records from their Laser surgery center? I requested my records two weeks ago and the office manager first told me that she had to check with the doctor first if she could send them. She called me back and said they would - nearly two weeks later I received them in the mail. As I was reviewing them, I noticed that they had a list of tests they had done on me measuring pupil size, cornea depth, etc. and they all said normal. They had one section called slit lamp test and it was not checked. Isn't that what they would have used to check for underlying issues with tear film, etc?

I am suspicious that I was not tested adequately prior to surgery. How would any of you handle this?

[Rebecca Petris]

I requested my records two weeks ago and the office manager first told me that she had to check with the doctor first if she could send them. She called me back and said they would - nearly two weeks later I received them in the mail.

That part about checking with the doctor is baloney. You have a legal right to those records, period, whether you are requesting them personally or another doctor's office is requesting them on your behalf. There should be a standard procedure in every medical office for copying and providing them and why a staffer should have to ask for a doctor's permission is beyond me.

I am suspicious that I was not tested adequately prior to surgery. How would any of you handle this?

Sad to say but most people aren't, frankly (for dry eye that is). Or if they are, tear film irregularity rarely prompts the doctor to recommend against LASIK unless it's pretty severe and even then they'll usually just recommend treating it before surgery.

[LauraK]

thank you for your feedback Rebecca. I was really put off by her having to check with the doctor. I just wish the doctors and their staff could be more sympathetic - they just don't seem to care.

[Scout]

HIPAA does state that medical records belong to the patient, so Rebecca is right that you have a legal right to your records. However, there is a clause that (totally paraphrasing here . . .) allows doctors' offices to refuse to immediately produce the records. If it is determined that the information within the records could be emotionally distressing or emotionally damaging in some way, the office could send the records to a third party to review and then discuss with the patient. Typically this is the patient's psychotherapist, counselor or psychiatrist. It also allows for a summary of the chart to be given to the patient in this case, as well.

So in my experience this is not unusual for the office staff to check with the physician first before releasing the chart to the patient. Most offices would give the treating healthcare professional the responsibility to make that decision, not the staff. The question of whether the records of a refractory surgery center could fit this clause . . . well, that seems like quite a stretch, in my opinion. But it is up to the treating healthcare professional to make that call, not the staff. So even if it is a stretch, it may apply here.

So good for you that you persisted. Some patients are intimidated by office staff who imply that the records belong to doctor's office, when they in fact belong to the patient.

Scout

[Blinks]

I've been on the receiving end of the run-around, too. My surgeon dragged his collective feet and despite my written request three weeks in advance, failed to send my records to an eminent cataract surgeon I'd opted to visit for a second opinion until AFTER my appointment date. (The second opinion was needed because I had worse vision after the surgery.)

After several follow up phone calls, I insisted on picking the records up in person, and I was charged $15 for ten sheets of paper. I hand carried them to the second opinion doctor, was told the records weren't of value because they were black and white (not the color topographic cornea maps).

So back I went to the original doctor again. The office staff tried to convince me the copier was out of color toner and when I asked if they could reprint from the topography machine they "thought" it had been replaced in the interim, and they probably couldn't print the maps out etc. I said I'd wait. After a half an hour, I was given the color maps. There's no happy ending to this story.

If you have questions about getting your records, try to check with your state consumer advocacy website as that's where I found the law which stipulates patient access to records, time delay allowed in providing records, and permitted photocopy charges.

In my state, doctors are only required to keep patient records for seven years. So I was unable to secure records from a previous surgery performed ten years ago.

Try to obtain and keep a current copy of your records, most particularly any surgical records with chart notes. They can become critically important.

Blinks

[Rebecca Petris]

Here's a great resource to understand your rights and the procedure for getting medical records:

http://medicalrecordrights.georgetown.edu/records.html

Click on your state at the right for details.

Here is an excerpt from my state, showing when and how they can withhold records. I cannot imagine that a LASIK provider could legally justify withholding records, unless they have evidence that you are overtly suicidal or homicidal.

Can My Provider Deny My Request for My Medical Record?
Yes. Your health care provider (including your mental health care provider) can deny your request to see or get a copy of your medical record, but only in a few cases. For example, if your provider believes that letting you see your record might physically endanger you or another person, they can deny your request.

How will I know if my request for my medical record has been denied?

Your health care provider must tell you in writing if they deny your request for your medical record. They must tell you why your request was denied. They also must tell you if you have a right to have their decision reviewed and how you can file a complaint.

Generally, under Washington law, your health care provider must give you this information within 15 days after receiving your request for your record.

Can my health care provider deny my request for my medical record just because they think I might get upset if I read it?

No. Your health care provider cannot deny you access to your record because they think the information in the record might upset you or that it might cause you mental harm. However, they can deny your request if they believe you will become upset enough to physically harm yourself or another person.

Can my health care provider deny my request for my medical record because I have not paid my medical bill?

No. Your provider cannot deny your request for your medical record because you have not paid your medical bill.

My medical record contains some information that my provider is allowed to deny me access to. Does this mean that I can’t get any of my medical record?

No. Your health care provider must give you as much of your medical record as possible. Your provider may remove only the information that they are allowed to refuse to give you access to.

p.s. If I sound like I have a chip on my shoulder, well, yup Back in 2001-2 I repeatedly requested my records as I had moved out of the country and was under other care. They ignored them over and over (I had outbound fax records to prove the requests were received). It turned out they were dragging it out because the statute of limitations for medmal was fast approaching. It was ridiculous, they had no reason to even suppose I intended to file. I finally sent them a letter that sounded like it was drafted by a lawyer, quoting chapter and verse of California law, and they coughed 'em up almost instantaneously.

[spmcc]

For example, if your provider believes that letting you see your record might physically endanger you or another person, they can deny your request.

Perhaps Lasik doctors could argue that they are the "other person" who might be endangered after releasing the records.

[Rebecca Petris]

*Grin*. Records denial slash restraining order on one handy form.

[poppy]

Has anyone else requested their medical records from their Laser surgery center? I requested my records two weeks ago and the office manager first told me that she had to check with the doctor first if she could send them. She called me back and said they would - nearly two weeks later I received them in the mail. As I was reviewing them, I noticed that they had a list of tests they had done on me measuring pupil size, cornea depth, etc. and they all said normal. They had one section called slit lamp test and it was not checked. Isn't that what they would have used to check for underlying issues with tear film, etc?

I am suspicious that I was not tested adequately prior to surgery. How would any of you handle this?

Never had LASIK but I've had exactly the same problem with getting information from doctors here (I'm in OZ). Receptionists won't for example give you a copy of pathology tests results without "asking the doc" and they do charge a fee if they decide to give them to you. It really annoys me, if I pay a fortune for blood tests, or I pay a fortune to a specialist only to have them tell me nothing (just write a letter to my GP) I should automatically be entitled to have a copy of the test result or letter posted to me. I shouldn't have to beg for it. It actually puts me off bothering with doing any tests a doctors orders because I know I'll never know the result apart from a phonecall if I'm about to drop dead. In OZ I believe that the medical centre owns the records (not the doc) although the patient does have the right to have the record transferred to another doctor for a "reasonable fee". Doctors justify this restriction of access to our records mainly by saying that it would "upset us" (um, then don't write remarks about our mental status, weight etc unless it's actually relevant and worded professionally!) or concerns that we would see an abnormal test result and overreact (well if my test result is "nothing serious" but still a bit off I say I still want to know, I paid for it!)

Most of the info I have about my eyes has been obtained from rare occasions where I've been able to access the letters that doctors write to each other, so I think it's definitely worthwhile trying to get this out of them.

[Rebecca Petris]

Poppy, I did a quick search. Try googling Patient access to medical records australia.

It's interesting, the law seems to be squarely on your side... Number 6 on this page identifies the situations in which they can deny you access and I hardly think they could justify treating occasional requests as "frivolous or vexatious". On the other hand, the Australian Medical Association is clearly discouraging doctors from giving patients easy access to their full medical records. It more or less says try everything else first (summaries, showing you bits only in their presence, etc). Eeesh. That's be enough to get me to write to a legislator I think.

[spmcc]

I love technology! Where I live, we can get our lab results online now! I've had doctors jump out of their skin when I told them I had a copy of my lab results and know everything they know (before them).

This doesn't help wrt doctor's notes. But find out if your lab has online access to results. I don't know how we got this in BC, but it's great!

Good luck.