Home Forums Discussions General Discussion receiving and sending medical records

two related issues are getting out of hand for me.
i wonder how others handle it
the first issue has to do with sending for and receiving medical records.
let's say this is a patient 4 years old, who moved to my area.
no hospitalizations, maybe had a few colds and an ear infection, had a series of physicals, etc.
well, here it comes. a bulk envelope with 150+ pages of fluff. yes, the visits are there, with shot records, but the fluff.
there could be something 'important to know' buried in the fluff. to read this report with intensity - to not miss 'anything' could take a couple hours - i wonder what others would considered a reasonable approach to reviewing bulky medical records like this - and then what to do with all this paper.
a second related issue is what to send to 'someone' requesting medical records from me, so as to be complete, and not be guilty myself of sending too much of my own fluff

I've wondered this myself, so others please weigh in. I often spend time sorting through it, then putting all the notes in one scan for the I.I., the labs in another, and so on. Labs over a year are probably worthless. One solution is not asking for "complete medical record" on an ROI, but Last 3 visits and imaging, or some such limitation.

Well, here goes. My completely uncaring different approach.

First, we get very few records through the mail. Mostly, they are faxed and a one page document takes up about as much space as a 250 page document. My staff labels it records, I import it, and that's that. I literally spend about five seconds on it. I do consults, and I would go through those, but I don't care at all what is in those records. I am assuming the patient's physician has already seen and dealt with those records. The responsibility is on parent or patient to let me know what is in the record. My MA and I ask them if there is anything in the record we should know about.

As far as if it is mailed, we scan it is, and shred the paper. We want the entire record.

When we send records, we usually send them via fax and scan if they are under 50 pages, otherwise we burn them to a disk and mail them. The way our software is set up, we can send all records, progress notes and vaccine record to the server, and it automatically makes a folder with their name. All of the information is automatically categorized so that when we combine them, it has the release on top, then the vaccine record, then the progress notes by date, then all records by category, i.e. cardiology, consults, demographics, discharge summaries, ED, Histories and so on up to orthopedics. On the very top of the PDF, is a sticky note with the number of pages and the charge for sending the record. The letter to the parent for the invoice is kept separate (if this is a transfer).

The record cannot be sent until an electronic stamp is stamped saying it is reviewed and OK for transfer. The front staff then burns the pdf to a CD (takes about 3 minutes after they stamp the date and time they sent it.

If it is simply a transfer for another reason, I just approve it via AC, and they do it. The whole process takes about 15 minutes from start to finish. The nice thing is that the record is always there when the other office calls and states they never got the record. If the patient wants a copy, it is on disk. We do NOT print the records. We never use a sheet of paper. The Xerox MFP has a huge hard drive also where these could be put.

We make a point not to send the messages as we think of these as work product. I wish I could get in the habit of not saying derogatory things in these comments. But, the receiving office never notices. When an attorney subpoenas it is it kind of embarrassing.

As to sending records for consults, we ask if they want the entire record. Most want the last progress note, etc. I find the histories and discharge summaries along with consults and labs, etc., are better than anything I type in five minutes in the room. If I know I am referring them, then I type a masterpieces. The crazy thing is that still in 2016 we have health facilities who do not receive records in a pdf. Massachusetts General Hospital still goes through reams of paper and yells at us if we send too much.

As to asking for certain records, personally I want the whole record. I really want to have all the information available, and it's not fair to the patient to have to ask for two or more offices to send records if they transfer again. It is completely legal for an office to send every page of their records, and if they don't after we call them, I contact the Board of Medicine. That works every time.

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

I applaud your diligence and your pride in your job. I apologize that I am so opinionated. But, for me it just makes more sense for a records transfer to be complete and done. You may know, but I know my staff and probably many others wouldn't know what they want. And, it is impossible to know. If I got a copy of records that said this is the past three years of a patient who was eight years old, I would immediately ask for the rest.

And, if I sent a copy of records to someone who asked for only such and such and send the rest later, I would tell them either take them all now or you will never get them. I know that sounds bad for the patient, it will take just as much time and now I have to do it twice.

In the old days, I can see not wanting to print 200 sheets of paper and then fax them all manually. But, it takes the same amount of time to make a pdf of all records and burn them to a CD as it does to send six months worth. In fact, it takes longer to go through and fine what they are requesting.

We send a very organized PDF file where every sheet has been scrutinized, fax cover sheets, duplicates and plain sheets of paper are deleted. I will admit that would take a bit longer on large files. But, once the pdf is made, it is in a folder with the patient's name in another folder called Transferred Records. Now we have a perfect copy to send if needed. Just today we got a release from another office wanting the same records we sent two years ago to another office. I am sure the parent simply put down each office. In fact, the other office is known for only sending records that they generate, which is crazy. There they are with 300 pages of our records and probably 30 pages of theirs. Now what does the mother do. She has to request them from us. We could make a big deal over it and tell the requesting office that we had already sent them. But, why? We can just use Windows Fax and Scan and send them in an hour. Plus, I don't think we have a choice anyway.

I will say that any office which won't send records they didn't generate is....well I won't even say.

Again, no offense. It sounds like you are incredible at your job. It just seems so much easier and even better for the patient if their entire record is now at the new provider's office. They can decided (especially with a pdf) which records they deem important and which they don't.

We used to have the records request form available on our website and at the reception for anyone who asked for it. We had let the parent fill out the form him/herself too. This lead to getting 200 page records because the parent always checks the "all records" box.

So we decided to take it off our website. I "hid" the PDF file so that staff can't find it and print it out. All copies of the forms are in the doctor's office only. The doctor will fill out the form completely (except for previous dr's address, phone, etc. - staff can look that up) and just ask parent to sign. Usually she just wants shot records and labs.

Some parents ask for this form before they see the doctor. We say no - the child has to see the doctor first and then she'll decide what records she wants.

However, some offices still send us the whole record even though "labs and vaccine records only" is on the form.

Patients fail to realize, IMO, that the physician isn't getting paid for the time that he goes through old records, unless the patient is sitting there in front of him. That's one reason why we don't request the records ahead of time, unless we specifically know that the patient has had prior imaging studies pertaining to the reason for their visit.
Which brings me to point number 2...when I ask a hospital for "Cranial Imaging Only" and they send me the patients ENTIRE visit record (if they were inpatient when the study took place, it can be quite lengthy). I just wanted the CT/MRI report and I got the Kitchen sink. Makes me shake my head. You get everything or you get nothing.

So, when you get the labs and vaccines from the other physician's office, and the patient transfers elsewhere, does the next office only get the labs and vaccines plus your new records? And, what if the prior office only asked for x-rays and vaccines? And, you wanted labs, but they don't have them? And, what is wrong with 200 pages?

Bert,

When patient transfers, we send whatever the new office asks for. If they ask for all records, we send our records plus all his/her records from prior office also.

If the previous office doesn't have lab reports then we don't get them.

We get LESS data than we request, in general. (I like to see years of lab work, not just the latest, which prompted the referral).
For outgoing Referrals, we likewise limit what we send, as in general there is a very narrow referral (chest pain, placement of dialysis access) and I attempt to outline that issue in latest note and letter.

Most of our outgoing records are for patient moving (entire chart , notes, inbound e-documents, lab, etc all burned to CD as PDFs) or a subpoena/request by lawyers for insurance/disability, etc. California law limits our charge in those circumstances to $15 (you can sure tell which profession writes laws in Ca), unless it is on microfiche (then 0.08 / page). We can charge additional $15/h for clerk time in Finding the records (not copying them, though). So they get a data dump of pdf files to CD as well, which is, shall we say, less than nicely organized.

I would just tell the new office that when the patient transfers again and the NEW office wants ALL the records, they aren't getting them from us. I am not doing everything twice. I will not send them until the board calls. In my opinion, and I respect yours, if a patient transfers their dog and their records should go with them.

Nested quote boxes, Bert. I believe that is a personal record.

I had to get rid of the nests. Way too fancy for me. But, so John's post makes sense, I did have a quote within a quote.

has anyone have an office refuse a cd- or a thumb drive.

i had an experience when i sent a cd; and the office told me the cd was 'broken'.
this was a large chart, so i put the records on a thumb drive and sent it that way; and the office contacted me to say that they do not accept cd's or thumb drives.

More disturbing is that a medical office lied to you, quite clearly. I don't see any reason you should print the paper unless someone is going to pay for record copy charges. Every medical office in the 21st century should have a computer, IMO.

I would simply have said, well that's fine, and we don't fax or mail records. I guess you will have to come get them.