I was the sole Medical Records person at one time and here is how I handled the situation in a 7 provider longggggg established family practice.
1. Trust in me by the providers was of the utmost importance and that came with knowing that I had common sense, CNA, Health Unit Co., PCT and ED experience.
]REQUESTING RECORDS- We requested minimal necessary for the age and if known the medical history of the patient. Newborn to 20"s IMMUNIZATION records were a MUST!!!!. NO EXCEPTION!
Adults we would still indicate any vaccinations (dTap, Flu, Pneu.,)etc:.
The average years requested however, were 3 years and no more. We could always ask for more if the provider felt more was needed. I would personally go through the records and look for surg, prob and immunization history and make marks indicating importance.
As I said, I knew my docs trusted me and I knew them well enough to know what they would be looking for. For paper charts everything was entered under prior records. For EHR, it is up to the providers office. The office I was working for then wanted all records from a previous Primary Care Provider to stay together. The one I work with now wants the records seperated (labs, x-rays, office notes).
RELEASING RECORDS-Basically I read over the records request from the requesting office. If the request said all and we had been seeing the patient over 5 years I would only send the last 3 years with a note indicating that more could be sent if needed. This also depended on if in the last 5 years there was only 5 visits or 20 with over 20 test.
Once again, MINIMAL NECESSARY is you biggest and best friend. You can always send more but, once it is sent you cant get it back.
I will sometimes send things that I do not see them ask for but, I know that the patient's care will better benefit if that doctor has that document on file.
The HIPAA law says MINIMAL NECESSARY first. Especially by mail and fax. I followed this rule for over 20 years in medical records.
PS __ Before copying a record onto disk, jumpdrive, paper or e-mailing go over EVERY EVERY page. You never know when one page is not that patient's record. Better safe than sorry. Records are a very serious and time consuming job when done correctly. Will save you money(fines) reputation and possible jail time.
Hope any bit helps.
Alley
