Cheryl Martin (Host): Did you know that the information in your medical records is owned by you, the patient? While you don't automatically get a copy when you are discharged from the hospital, you can request it for personal use. Annissa Pierce, Director of Health Information Management and Facility Privacy Officer is here to cover the basics on the process and patient's rights. This is Health Talk with the Valley Health System presented by the Valley Health System. I'm Cheryl Martin. Annissa, so glad you're here with us to discuss some important information for patients.

Annissa Pierce, RHIA: Absolutely. I am so happy to be here.

Host: First, please explain what a medical record is and what types of information it typically includes.

Annissa Pierce, RHIA: Yes, absolutely. So a medical record is composed of numerous entries documented by various providers, meaning nursing, physical therapists, doctors. All health disciplines will document a note after they've seen you as the patient to compose the care that they've given while you were seen at that facility.

Each piece of documentation that they create is all rounded together, and that is what creates the patient's medical record. There is a medical record created every time a patient is seen, and we keep that all together in our electronic medical record system.

Host: Now, are there different types of medical records, and if so, how do they differ? You mentioned that each person will document the information, but any other differences in terms of medical records?

Annissa Pierce, RHIA: Sure. That's a great question. So we, when the patient comes to, let's say a hospital, we assign a level of care. So a lot of patients will come to the hospital, through our emergency department, and based on the nature of care that they need, we will determine what level of care they need. Some patients simply need to be seen in our emergency room and they can go home after that. Some patients may need to be admitted and stay in the hospital for a couple of days. We call that an inpatient stay. Some patients just need to be here a couple of days for observation to see if the condition worsens or potentially gets better.

And those are observation stays. We have patients that come to the hospital just for surgery, and those are ambulatory surgery type of records. So that's how we kind of decide what kind of medical record it is based on the level of care the patient is receiving.

Host: So why is it important for people to understand their medical records?

Annissa Pierce, RHIA: It is important that our patients understand their medical records because, we want to make sure that what's in the medical record is accurate, true and timely. Also, when you think of the billing component, our patients are paying premiums for their healthcare insurance and then, at times their insurance does not cover the full service.

And so we want to make sure that the service they receive and that they're being billed for, and the portion of that bill that they are responsible for, is accurate and true. So it is important that they understand the contents in their record, for their responsibility.

Host: So who legally owns a person's medical record?

Annissa Pierce, RHIA: Legally, the patient owns their medical record, however, the facility maintains the patient's medical record.

Host: So then what rights do patients have when it comes to accessing their own medical records?

Annissa Pierce, RHIA: Absolutely. That is a good question. The patient has a right to their medical record, and they can express that right by coming into a medical records department. Sometimes if it is in a clinic, you can just go to the front desk. At hospitals they'll have a medical records department and the patient can fill out a release of information authorization form so that they can have a copy of their medical record and they can decide what they feel they need.

They can have the entire record, they can just have their immunization records, whatever they feel they need, it is their right to have access to that portion of the record.

Host: So what measures are in place to protect patient privacy?

Annissa Pierce, RHIA: That is a great question. There are several federal regulations in place. The most well known would probably be HIPAA, the Health Insurance Portability and Accountability Act. HIPAA is not the only governing legal realm for medical records. There's also regulations that we have to follow from the federal government, from OCR, from Health and Human Services.

Also, there's other privacy laws in place protecting our substance abuse population, governed by 42 CFR part two. But basically with all those privacy regulations, most facilities will create their own policies that mirror those federal regulations so that we are in compliance with them.

There are also state level privacy rules. So as it goes with medical record science, we are to follow whatever the most stringent laws and policies are that are out there. And so yes, patients do have the right to access their medical record information. We also have the obligation to follow state and federal laws and regulations when it comes to the release of their records.

Host: Now, you mentioned before that if a patient wants the records, you have a medical records department, and that's where they would start. Anything else they need to know? Let's say a surgery or a procedure took place five or 10 years ago, how far can they go back?

Annissa Pierce, RHIA: That is an amazing question. So this is where policies and regulations come into place. So the regulation for retaining a medical record, about 15 years ago was that we had to keep records for 10 years. Today that has been updated that we have to keep records for six years. However, when it comes to minor patients, we are obligated to keep their records for until the patient turns 18 years of age as well as an additional five years.

So, the different records have different retention timeframes. And then if a record is under litigation, we would want to hold onto it longer than that. But right now, we are maintaining records for six years in compliance with federal regulations.

Host: So do you recommend that patients always request their medical record?

Annissa Pierce, RHIA: I am recommending that patients know how to access their medical record. I don't think your average patient needs a copy of their record laying around at home. It may not service them. Sometimes when things have happened, so far, so long ago, it may not be as effective such as, you know, if there's a recurrence of a condition, it may require more recent imaging, it may require more recent lab work. So sometimes having information isn't as beneficial because it could be outdated. However, you should always know how to access your information. Here at the Valley Health System, we have a patient portal where patients can go to access their records.

Again, they can always come into medical records. They can also request their records online and we can send them the link to their records through an email and they can download it onto their computer. And so I would recommend that you always know how to get your record. You never know when you would need your record, but you do want to keep in mind that certain things, is not as helpful to hold onto because it could be outdated and not as helpful to your providers.

Host: That's great to have all those options. Now, what is a power of attorney and why is it important to have one?

Annissa Pierce, RHIA: Yes, so Power of Attorney is a legal document that basically authorizes someone else to act on your behalf. You as a patient can decide who that person should be. It should be somebody you trust, I would say, you know, love and trust. But that is the patient's responsibility to deem who that would be.

Now, I do want to say that there is a difference between just a power of attorney that typically governs property and banking information. You want to make sure that when you are drafting up a power of attorney for healthcare purposes, that it is a healthcare power of attorney that is going to give your person of choice, the opportunity to make healthcare decisions for you, to request your records, to request corrections on your records and things of that nature.

Host: Now if a patient passes away, what is the process for requesting their medical records?

Annissa Pierce, RHIA: Yes. That's a great question. And that answer does vary from state to state because that's one of those things where the state can have more stringent regulations than, the federal government requires. Here in Nevada, we do require, that you have legal documentation proving that you are the person who can access those records.

One thing to keep in mind is that power of attorney and guardianship paperwork is null and void once your loved one expires, unfortunately. So that's where we would need court documentation of ex parte. It could also be a will. A handwritten will or a legalized notarized will that the patient put in place prior to their expiration.

So we would need legal documentation before we could just give the records to your loved one.

Host: Now, should you also request your records from your personal physicians in addition to the hospital?

Annissa Pierce, RHIA: You should or at least have a way to access those records. Everybody, you never know what type of condition may come up. When you round up your medical records, you may need to create a full picture for, let's say a specialist. Let's say it came down after testing and observations that you're having some sort of cardiac issue.

You might want to take all those records to your cardiologist so that they can review and really have a full picture of what you've experienced. So it is best to have your information from the hospitals you've been seen at as well as any specialist or other family medicine providers.

Host: Well, Annissa Pierce, you have shared some great information that I believe all patients need to know. Thank you for educating us.

Annissa Pierce, RHIA: Absolutely. It was a pleasure. Thank you so much for having me today.

Host: For more information, visit valleyhealthsystemlv.com. Now, if you found this podcast helpful, please share it on your social media and check out the full podcast library for other topics of interest to you. This is Health Talk with the Valley Health System presented by the Valley Health System. Thanks for listening.

Physicians are independent practitioners who are not employees or agents of the Valley Health System. The system shall not be liable for actions or treatments provided by physicians.