How to Access Patient Information

While the act of picking up a file and reviewing information on a patient seems so simple, there are numerous rules and regulations that must be followed. The federal Health Insurance Portability and Accountability Act (HIPAA) mandates strong protection of patient privacy which includes all medical records. HIPAA goes well beyond medical facilities and doctors' offices. It affects how files are transmitted, stored, sent and handled by medical personnel, facility staff, insurance carriers and systems administrators. As a result, there are limited and specific ways to access patient information.

Instructions

• 1

  Ask for your own medical records if you are the patient. HIPAA and numerous state laws give patients the right to their own information. Medical providers, insurance companies or other record-holders must release it to you provided they can positively identify you as the patient.

• 2

  Present an authorization from the patient for medical records release or documents showing your power of attorney or guardian ad litem status. These give you the right to access patient information on behalf of the patient.

• 3

  Deliver a subpoena or court order signed by a judge.

• 4

  Find the patient's chart and any associated records in a closed folder either in the patient room or the nursing station if you are a medical practitioner at a hospital that still uses paper records. Because healthcare providers have until 2020 to shift to Electronic Medical Records (EMR), practitioners must know both paper and electronic protocols. Hospital policies vary about the proper location of a closed patient folder, but almost all require patient information to be kept in opaque folders in locations not easily visible to visitors and unauthorized persons. Alternatively, login to your medical facility or office's HIPAA compliant EMR system. Position yourself so that the screen is not visible to onlookers while you read and chart. Close all files and log out at the end of your session. Nurses, doctors and others who are authorized have a responsibility to keep visibility of patient records minimal while working with them.

• 5

  Retrieve medical records from your company's secured file containers or encrypted database if you work for an insurance company. Access only records for cases you are personally adjudicating or servicing. Close both paper and electronic files as soon as you are finished or anytime you leave your computer terminal. Always put paper files back in their secure files or containers as soon as you finish with them.