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OUTSIDE
MEDICAL RECORDS:
What to Do When
You Get Them
by Waldene Drake, RN, MBA
Vice President, Risk Management
and
Dan Groszkruger, JD, MPH
Consulting Editor
There is no arguing that diagnostic test results
provide important information. When a physician
orders that test or diagnostic exam, he or she is
responsible to know the results. (See “Don’t Let
Late-Returning Tests Boomerang On You,” later in
this issue.) But what about test results, diagnostic
exam results, and other medical records that you
did not order? If they are in your possession,
are you also responsible for their content? Or,
in the case of current patients, what are the risks
of requesting copies of the patient’s records from
former physicians?
In the course of assuming care for new patients,
physicians frequently inherit copies of these new
patients’ earlier medical records.
But what duties does a physician have when medical
records arrive at the office? Are you obligated to
read voluminous, irrelevant, historical records
simply because someone
decided to send them to
you? Can you simply
ignore or discard them?
What risks are associated
with filing them, unread,
along with the patient’s
chart?
How do you know, short of
reviewing the entire chart,
whether outside medical
records contain important
information? Obviously,
you can’t! But, you are
taking a big risk if you
simply ignore or discard
them! Because there is very
little in the way of specific
rules or requirements for
handling these records,
common sense must guide
your decision. Some
precautions follow:
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Consider the following scenario:
A 50 year-old woman, who recently moved to
the area, makes an appointment for a routine
check-up and physical exam by an internist.
The patient complained of intermittent back
pain. Otherwise, she claimed to be in good
health. She did not report any other health
concerns. Shortly after her visit, the
internist’s office received a chart, forwarded
by the patient’s former doctor in Michigan.
Included was a report of a recent CT scan,
demonstrating a descending aortic aneurysm,
7.5 cm in size. The medical literature and the
standard of care classify an aneurysm of this
size as a surgical case. No action is taken after
receipt of the Michigan chart. Several months
later, the patient experiences severe symptoms,
and dies suddenly. On questioning, the
internist cannot remember if he ever saw the
CT scan report. |
- One precaution is adoption of a policy to ensure
that such records are not simply filed, unread,
along with your patient’s chart.
- A few sections of the medical record merit
careful review. These include hospital discharge
summaries, history & physicals, consultations,
special procedures, radiographic studies, and
operative reports
- A review of medications in the old medical
record may also be a clue to diagnoses which
may be buried in the file.
- The outside records may contain sensitive
information (e.g., HIV-AIDS, other STDs or
mental health treatment) that is specially-protected,
and should be distinguished from
other, less-sensitive documents.
- Depending upon the patient’s current condition,
you may have no practical option but to read
the entire chart! In a later malpractice law suit,
how can the physician plausibly explain his
ignorance of information
that was “right under his
nose?”
With these thoughts in
mind, physicians should
think how their own
records could be improved
to avoid errors caused when
important issues are
overlooked.
- Use a medication list to
track your patient’s
medications
- Make sure those on your
staff document all
medication refills
- Use a problem list to
track the conditions you are
monitoring
- Establish protocols for physician review of diagnostic tests
- Document date of review on all diagnostic tests, and the follow-up needed
What about unsolicited records?1 Generally speaking, the procedures covering storage and eventual
destruction of your office records need not apply to unsolicited records, if you have not made them
a part of your own chart. After determining that outside records contain no useful information, there
should be no problem destroying them. But, if the records are not likely to be useful, why not simply
return them to the senders (or if the source is unclear, turn them over to your patient or family
members)? Prudence would dictate that you take reasonable steps to transfer possession of such
sensitive records to the rightful owner, before shredding or destroying them.
1 Sources include: (a) records requested by your patient, from hospitals, prior treating physicians or
consultants, and (b) records from a retiring physician’s office, an insurance company, or a government
agency, upon notification of your taking over the patient’s care.
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