What Should We Include When Filling a Patient’s Records Request?

Q.  If a patient requests a copy of his or her medical records, do we give only the records created in our office, or do we include hospital records, lab, x-ray, pathology and referring physician records that were sent to us?

 A.  You should include the additional records in addition to those your office generated. The Medical Practice Act defines the term "medical record" as "all records pertaining to the history, diagnosis, treatment or prognosis of a patient."

In its list of elements that constitute a medical record, Texas Medical Board Rule 165.1 says: "Records received from another physician or health care provider involved in the care or treatment of the patient shall be maintained as part of the patient's medical records."

 

TMA Practice E-tips main page  


Comment on this (Must be logged in to comment)

Add Comment

Text Only 2000 character limit

Looking for more?