Practitioner Pointer: How to handle record requests from patients
Some psychologists may be experiencing an increase in patient requests for their health records as patients become more active and involved consumers of health and mental health services. What would you do if a patient asks for a copy of his or her patient record? Practitioners should educate themselves in advance about how to respond to these requests.
Although psychologists, or the organizations for which they work, maintain the original health records, federal and state law generally entitles patients to obtain copies of their records. So if a patient makes such a request, you generally must comply and provide the patient with a complete copy of his or her record. (Some state laws provide for limited circumstances where releasing a records summary may be permissible.)
While patients do not have to give you a written request to see their records, it’s a good idea from a recordkeeping standpoint to ask them to sign an acknowledgment or otherwise document that you have given them a copy.
The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule establishes standards for patients to access health information in their record. If state law grants patients greater access than HIPAA does, the psychologist must comply with state law.
Under both HIPAA and state law there are instances when the psychologist may be entitled to limit patient access to information in the record, such as if the psychologist is concerned that allowing access would likely endanger the life or physical safety of the patient or another person. There are additional situations where determining who can access the record is more complicated than a standard request by an individual adult patient — such as when the patient is a minor, or when a couple, family or a group is receiving therapy.
The APA Ethics Code and Record Keeping Guidelines support the patient’s right to access his or her records. Marketplace trends are expanding patient access to information in health records. Combined with the trend toward greater patient engagement in their health care, psychologists ought to familiarize themselves with HIPAA and relevant state laws. Practitioners need to understand what rights their patients have to access their own records, while also ensuring that they release the records in accordance with applicable law and the Ethics Code.
Note: The information in this article does not constitute legal advice and should not be used as a substitute for obtaining appropriate professional consultation prior to making decisions regarding individual circumstances.
For additional information, contact the Office of Legal and Regulatory Affairs by email or by phone at 202-336-5886.
Practitioner Pointers provide answers from APA Practice staff to common inquiries from members.