Are You Making These Mistakes With Records Releases?

When a records request hits your desk (or virtual fax line in my case) what do you do next?

Download and send the entire record to get it off your plate? Ignore it for as long as possible? 

I wanted to share my best tips that might prevent you from making these common mistakes with records releases!

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So *fingers crossed* my hope is that you respond to all records requests.  HIPAA dictates that a client has a right to access their medical record (including requests for parts of the record to be sent to other professionals with limited exceptions) with a 30 day turnaround time. 

Best practices? You have your client sign a release of information in your medical record and you have a clear discussion about what will be sent and why.  See more HERE about why you need to be thoughtful about what is sent and why according to the minimal medical necessity. 

But what about when best practices don’t apply? Maybe the records request comes from a different agency? Maybe there is a need for a tight turnaround on sending the records? Maybe the client is no longer in your care but needs another provider to have records? 

First things first I always recommend calling the client to verify what records they would like sent and verify that they want those records released. I would also recommend documenting this conversation along with the typical documentation you do when you release any PHI.  

Next, I would recommend that you verify the release of information, paying specific attention to the following points: 

What is the ROI requesting? There are some releases of information that are only requesting verbal communication and will specifically say *not a request for records*.  Here, the client has only given consent for verbal communication and NOT for sending records. 

Another great example of this is an ROI I recently received that had boxes of lab reports, Xrays, CT images, EEG report, and Sleep Study requested. Needless to say I did not have blood work or any of the other boxes checked that pertained to this client. Situations like these may necessitate a phone call to clarify what the requesting party is actually wanting.  

What is the date range of information requested? Sometimes the date range the ROI is requesting may have only several pieces of documentation that goes along with this timeframe. If so, we are only allowed to release records within this frame. 

Is there a signature? This one is huge! I have received Releases of Information with absolutely no signature or date on them. In these cases you want to have the client sign an ROI directly with you or communicate to the requesting provider that you did receive the ROI but due to not having a signature you are not able to move forward. 

Hopefully these four tips can help you navigate your next records request like a pro!  

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