Medical Records
What is a 'medical record'?
A medical record is simply a permanent history of all the care and treatments that you get when you're in a doctors office or in a hospital.
Who owns my medical records?
You own your medical record, but the hospital or the physician will keep that medical record as a custodian for you, and safeguard that medical record consistent with the laws that guarantee your privacy.
What information does my medical record contain?
Your medical record contains a whole host of information about you. Some of it's demographic, and that means personal information about who you are, the type of insurance, the name of your primary care doctor, your address, phone numbers, and things of that nature. Another section of the medical record has administrative information in it. For example, if you're in a hospital, the forms that show that you agreed to be admitted and treated, documents related to financial arrangements, authorizations for treatment, etc. Another section, the major section of the medical record, has reports about your care, the history and physical examination, your medical and nursing care plans that have been developed, charting and notations that have been made about your progress during your hospital stay, instructions and orders given by your physicians, medications that have been ordered and given and when they have been given, results of diagnostic tests that were ordered for you, observations of your condition and progress made by the physicians, the nurses, and other health care providers, your diagnosis and treatment. All of these elements make up your permanent medical record, the history of your stay or your history of your relationship with your physician.
Why are medical records kept confidential?
Your privacy rights are very strictly enforced because federal law, called HIPAA, is designed to guarantee that your privacy will be respected by hospitals - by nurses, by office staff working in doctors offices - because we believe that is a very personal and private set of information. Even though many people in a hospital have access to your records, doctors nurses, technicians - all of us - accept the responsibility to keep the information about you very private. You have the right to believe that your record will not be read by anyone who is not involved in your care. You have the right to expect that your condition and medical record will not be discussed with anybody other that those that are involved with your care. As I said before, your privacy rights are guarantee by HIPAA, Health Insurance Portability and Accountability Act.
Do medical records expire?
Medical records don't necessarily expire, but hospitals and physicians have a responsibility to keep them for a certain length of time. Every state has slightly different rules and regulations about how long they have to be kept. They always have to be kept for at least seven years, and in some states, records for children must be kept until they become adults.
