Every facility with which I have worked has had family members or residents request copies of their charts. The request may be as the result of an incident, may be simply to keep medical providers updated or may be for transfer purposes. Regardless of the stated reason, it is not an over-reaction to be concerned.
When a chart request is made, an appropriate response is for the administrator or a designee to speak with staff providing care to find out if there are any issues with either the resident or the family. If the family members have raised concerns, it may be time to get the administrator involved.
Making records available to the resident is fairly uniformly permitted because the resident is the subject of the records; however, it should be noted that the chart is usually considered the property of the facility. A major problem with chart production comes with making the records available to family members. Verification of the relationship of the family member to the resident is a common practice to prevent unauthorized access to personal health information. Admission documents for some facilities include resident specifications of family members who are and are not allowed access to medical information. Generally, the facility is expected to honor those preferences. Family members or others who have medical powers of attorney or general powers of attorney are generally expected to have access to medical records; however, the authority granting instrument should be reviewed to verify scope of authority. Guardians or other court-appointed responsible parties may also have authority to obtain a copy of the chart, depending on the purpose of the appointment. The important point is to verify the role of the person requesting the chart to make sure personal health information is not being improperly distributed.
Once the initial verification is completed, the facility’s task is to review the entire chart to ensure that information that does not belong in the chart is removed. Incident reports and investigation documents are not part of a resident’s chart. Disciplinary actions against an employee related to care provided to the resident are not part of the resident’s chart. The chart contents are typically only documents related to the care provided to the resident, including care plans, assessments and MDS forms. Before sending out the chart, it is a common practice to review the chart for any incomplete information. Late entries can be appropriate to complete the record as long as they are entered and identified as late entries. If review of a chart indicates potential for future problems with the family or resident, it may be wise to bring those findings to the attention of the administrator. Except when the resident remains at the facility, no chart entries related to care provided are appropriate after the chart has been copied and sent out. It is a good practice to maintain a facility copy of what was sent to the family or resident. In a litigation matter, everyone’s copy of the chart should be the same.
After the chart has been reviewed and two copies have been made, the facility needs to provide it to the family or resident within a prescribed time. Most states have statutes governing the turn-around for production of a chart. In Virginia, the facility has 15 days to produce the chart. The facility can charge a reasonable fee for copies, postage and labor. Some state statutes dictate the fees that can be charged when family or the resident requests chart copies.
When providing a copy of the chart to the resident or family, it may be a good opportunity to have a conversation about resident or family concerns in a non-adversarial environment. Remember that chart requests can be a desire to have full information and they can be the harbinger of litigation.