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Shit don't
mean shit
posted
I am currently seeing a GI Doc about a stomach issue I am having. During the visits with the GI doc and my PCP they often take notes on the computer. The doc has an online patient portal. The info in the portal has very basic information, and not the detailed notes the doctor takes during the meetings.

Generally speaking, are these detailed notes made available to patients? Is there a reason a doc would not want to give patients access to this info?

I don' think my doc would refuse to give access, but I was curious if patients normally ask for access. What's the protocol?
 
Posts: 4286 | Location: 7400 feet in Conifer CO | Registered: November 14, 2006Reply With QuoteReport This Post
Thank you
Very little
Picture of HRK
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Interesting question, my PCP has a web portal as his practice is part of a larger group of medical practices lumped into one.

I get emails of updates, information etc and there is never anything there, they ask patients to sign up however in 4 years I've yet to see anything other than the information I entered, nothing on appointments, history, prescriptions etc.

Why have it if you're not going to update it.



"My rule of life prescribed as an absolutely sacred rite smoking cigars and also the drinking of alcohol before, after and if need be during all meals and in the intervals between them." Winston Churchill
 
Posts: 12107 | Location: FL | Registered: November 07, 2008Reply With QuoteReport This Post
Info Guru
Picture of BamaJeepster
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They are your records and you have access to them with only a few exceptions.

(I'm not a doctor, my ex wife is and I set up her office and had to know HIPAA rules).

Here are the details along with statute references:

https://www.hhs.gov/hipaa/for-...l-records/index.html

Your Medical Records

Health care professional and medical filesThe Privacy Rule gives you, with few exceptions, the right to inspect, review, and receive a copy of your medical records and billing records that are held by health plans and health care providers covered by the Privacy Rule.

Access
Only you or your personal representative has the right to access your records.

A health care provider or health plan may send copies of your records to another provider or health plan only as needed for treatment or payment or with your permission.

The Privacy Rule does not require the health care provider or health plan to share information with other providers or plans.

HIPAA gives you important rights to access - PDF your medical record and to keep your information private.

Charges
A provider cannot deny you a copy of your records because you have not paid for the services you have received.

However, a provider may charge for the reasonable costs for copying and mailing the records. The provider cannot charge you a fee for searching for or retrieving your records.

Provider’s Psychotherapy Notes
You do not have the right to access a provider’s psychotherapy notes.

Psychotherapy notes are notes that a mental health professional takes during a conversation with a patient. They are kept separate from the patient’s medical and billing records. HIPAA also does not allow the provider to make most disclosures about psychotherapy notes about you without your authorization.

Corrections
If you think the information in your medical or billing record is incorrect, you can request a change, or amendment, to your record. The health care provider or health plan must respond to your request. If it created the information, it must amend inaccurate or incomplete information.

If the provider or plan does not agree to your request, you have the right to submit a statement of disagreement that the provider or plan must add to your record.

See 45 C.F.R. §§ 164.508, 164.524 and 164.526, and OCR's Frequently Asked Questions.

More specific info on your rights:
https://www.hhs.gov/sites/defa...ighttoaccessmemo.pdf



“Facts are stubborn things; and whatever may be our wishes, our inclinations, or the dictates of our passions, they cannot alter the state of facts and evidence.”
- John Adams
 
Posts: 27362 | Location: TN/KY | Registered: June 29, 2001Reply With QuoteReport This Post
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Picture of Censored
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You do have a right to the information. Reach out to your docs office and ask what the process is for requesting. You will not be able to access it online per se, but should be able to get a .pdf copy.
 
Posts: 2011 | Location: United States | Registered: February 13, 2006Reply With QuoteReport This Post
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This is only part of the issue , but the Feds have forced healthcare to have all records on computers.

Called Electronic Medical Records ( EMR) ....they reimburse the docs and hospitals better.

One issue is that the folks who have designed these systems , couldn't put on a band-aid... Then they expect the docs many of whom are not very computer savvy anyway to negotiate these very awkward software programs....Many are simply giving up and not doing it and others are actually hiring "scribes" to do nothing but handle the computer charting......and somewhere, someone is sitting back and calling it progress....
Horribly inefficient....sorry, I'll get off the soapbox now, mike

PS: You do have every right to your info !
 
Posts: 742 | Location: Idaho | Registered: October 21, 2007Reply With QuoteReport This Post
Member
posted Hide Post
quote:
I am currently seeing a GI Doc about a stomach issue I am having. During the visits with the GI doc and my PCP they often take notes on the computer. The doc has an online patient portal. The info in the portal has very basic information, and not the detailed notes the doctor takes during the meetings.

Generally speaking, are these detailed notes made available to patients? Is there a reason a doc would not want to give patients access to this info?

I don' think my doc would refuse to give access, but I was curious if patients normally ask for access. What's the protocol?


I would ask your doctor at the next visit, and be explicit as to why you need the information. The notes are not provided because many patients would have difficulty understanding them unless they are familiar with medical jargon.
 
Posts: 3424 | Location: MS GULF COAST | Registered: January 02, 2015Reply With QuoteReport This Post
Shit don't
mean shit
posted Hide Post
I do know they are my records. For example, I had a fibroscan done (basically a type of ultrasound of the liver to check for fatty liver, and other things). The doctor had the results on her monitor as we were talking about the results. I asked for a copy and she didn't hesitate, no problem. I got it when I left.

Before I left I was in the process of scheduling my next appointment. I could hear her a few doors down dictating our meeting. Probably to have it transcribed later, not sure. When I see her again I'll ask, but I am not sure what I ask for. Is there a specific, technical name for the notes? "Hey doc, I'd like a copy of ____________ from our visits."

I just want to know what I should ask for, and if this is a common request from patients.
 
Posts: 4286 | Location: 7400 feet in Conifer CO | Registered: November 14, 2006Reply With QuoteReport This Post
Happiness is
Vectored Thrust
Picture of mojojojo
posted Hide Post
Just ask for a copy of your medical records. If you want just the notes from your office visits just ask for that - that way things like labs, etc. won't be included.

One other note - while someone can appeal or ask for their record to be corrected, it doesn't always happen as requested. If the record is correct then they don't have to amend it. We had a patient who objected to their child being listed as obese and wanted it changed. Nope. The record was correct so it stands as is.


___________________________________________

Icarus flew too close to the sun, but at least he flew.
 
Posts: 5628 | Location: North Carolina | Registered: April 30, 2003Reply With QuoteReport This Post
I believe in the
principle of
Due Process
Picture of JALLEN
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As the reference to “obese” above illustrates, doctors very often use terms which have very precise medical definitions, but unfortunate or negative inferences in civilian parlance.

Most of the rest is gibberish to us unwashed medically illiterates anyway.




Luckily, I have enough willpower to control the driving ambition that rages within me.

When you had the votes, we did things your way. Now, we have the votes and you will be doing things our way. This lesson in political reality from Lyndon B. Johnson

"Some things are apparent. Where government moves in, community retreats, civil society disintegrates and our ability to control our own destiny atrophies. The result is: families under siege; war in the streets; unapologetic expropriation of property; the precipitous decline of the rule of law; the rapid rise of corruption; the loss of civility and the triumph of deceit. The result is a debased, debauched culture which finds moral depravity entertaining and virtue contemptible." - Justice Janice Rogers Brown
 
Posts: 47064 | Location: Texas hill country | Registered: July 04, 2005Reply With QuoteReport This Post
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quote:
Originally posted by JALLEN:
As the reference to “obese” above illustrates, doctors very often use terms which have very precise medical definitions, but unfortunate or negative inferences in civilian parlance.


That's a big part of it. The language in chart notes is often very cold and rigid. Many patients take it personally. It's not.
 
Posts: 7221 | Location: The Red part of Minnesota | Registered: October 06, 2002Reply With QuoteReport This Post
Info Guru
Picture of BamaJeepster
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quote:
Originally posted by 1967Goat:
I just want to know what I should ask for, and if this is a common request from patients.


Not uncommon.

If you want a specific office visit, just ask for the records relating to your appointment on xx date.

If you want a complete copy just ask for a copy of all your records they have.

They will probably ask you if you just need them sent to another doctor - just explain that you want a copy for your own records.

They have the option to generate a copy while you wait or tell you that they will be sent to you in a few weeks. They also have the option to charge you a 'reasonable' fee. Something like 25 cents per page. They don't have to charge you, but they do have the right to if that's their policy. You'll just have to ask them.



“Facts are stubborn things; and whatever may be our wishes, our inclinations, or the dictates of our passions, they cannot alter the state of facts and evidence.”
- John Adams
 
Posts: 27362 | Location: TN/KY | Registered: June 29, 2001Reply With QuoteReport This Post
Something wild
is loose
Picture of Doc H.
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All of the above, with the exception of some mental health records and a few legal zebras. They are your health records and you have a right to see them.



"And gentlemen in England now abed, shall think themselves accursed they were not here, and hold their manhoods cheap whiles any speaks that fought with us upon Saint Crispin's Day"
 
Posts: 1840 | Location: The Shire | Registered: October 22, 2011Reply With QuoteReport This Post
Nature does not hurry, yet everything is accomplished
posted Hide Post
quote:
Originally posted by mike28w:
This is only part of the issue , but the Feds have forced healthcare to have all records on computers.

Called Electronic Medical Records ( EMR) ....they reimburse the docs and hospitals better.

One issue is that the folks who have designed these systems , couldn't put on a band-aid... Then they expect the docs many of whom are not very computer savvy anyway to negotiate these very awkward software programs....Many are simply giving up and not doing it and others are actually hiring "scribes" to do nothing but handle the computer charting......and somewhere, someone is sitting back and calling it progress....
Horribly inefficient....sorry, I'll get off the soapbox now, mike

PS: You do have every right to your info !


At least something is working some of the time. My mother was hospitalized last week out of state and all her records from that visit were accessible to her PCP by today here in NC and I'm not aware of any particular difficulty in the doctor's ability to access them. Good thing too otherwise she would probably be repeating tests now that she had then.
 
Posts: 3814 | Location: NC | Registered: December 20, 2004Reply With QuoteReport This Post
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