Health Information Management (Medical Records)
Health information management or medical records, is a department organized to manage health information data by ensuring its quality, accuracy, accessibility and security in both paper and electronic systems. There are various classification systems used to code and categorize patient information for reimbursement purposes. Databases and registries are also used to maintain patients’ medical histories as well as treatment histories.
Medical records technicians document patients’ health information, including the medical history, symptoms, examination and test results, treatments, and other information about healthcare provider services. Medical records and health information technicians’ duties vary with the size of the facility in which they work.
Although medical records and health information technicians do not provide direct patient care, they work regularly with physicians and other healthcare professionals. They meet with these workers to clarify diagnoses or to get additional information to make sure that records are complete and accurate.
The increasing use of an electronic health record (EHR) will continue to change the job responsibilities of medical records and health information technicians. Technicians will need to be familiar with, or be able to learn, EHR computer software, follow EHR security and privacy practices, and analyze electronic data to improve healthcare information as more healthcare providers and hospitals adopt EHR systems.
FAQ about HIM/Medical Records
Is there a law that says I can see or copy my medical records?
You can make a written request to either review or obtain a copy of your medical records pursuant to Health and Safety Code sections 123100 through 123149.5. The laws which authorize access to your records are available on the Internet and you might wish to review them for information about time lines a physician has to meet and the fees he or she may charge to provide the records.
How do I obtain copies of my lab results?
Health and Safety Code section 123148 requires the health care professional who requested the test be performed to provide a copy of the results to the patient, if requested either orally or in writing. When the patient requests his/her lab results, the health care provider should provide the results to the patient within a “reasonable” time period after the results are received by the provider. Depending on the results of the tests, some physicians may want the patient to schedule an appointment to review and discuss the results and any follow-up testing or treatment that might be required. The test results cannot be released by the lab performing the test and must be released by the provider requesting the test(s).
Can a doctor charge me for copies of my medical records or x-rays?
Yes, pursuant to Health & Safety Code section 123110, a doctor can charge 25 cents per page plus a reasonable clerical fee. For diagnostic films, such as an x-ray, MRI, CT and PET scans, you can be charged the actual cost of copying the films. This only applies if you have made a written request for a copy of your medical records to be provided to you. Always make sure you ask what the charges are at each facility you are requesting from.
How long does a physician need to retain medical records?
There is no general law requiring a physician to maintain medical records for a specific period of time. However, there are situations or government health plans that require a provider/physician to maintain their records for a certain period of time. Several laws specify a three-year retention period: Welfare and Institutions Code section 14124.1 (which relates to Medi-Cal patients), Health and Safety Code section 1797.98(e) (for services reimbursed by Emergency Medical Services Fund), and Health and Safety Code section 11191 (when a physician prescribes, dispenses or administers a Schedule II controlled substance). The Knox-Keene Act requires that HMO medical records be maintained a minimum of two years to ensure that compliance with the act can be validated by the Department of Corporations. In Workers’ Compensation Cases, qualified medical evaluators must maintain medical-legal reports for five years. Health and Safety Code section 123145 indicates that providers who are licensed under section 1205 as a medical clinic shall preserve the records for seven years. However, there is no general statute which relates to all other types of medical records.
How long does a physician have to send me the copy of medical records I requested?
If you made your request in writing for the records to be sent directly to you, the physician must provide copies to you within 15 days. The physician can charge a reasonable fee for the cost of making the copies. If the physician’s office advises you that a fee will be charged for the records, the medical records do not need to be provided until the fee is paid. If the physician does not comply within the time frame you can file a written complaint with the Medical Board.
How can I correct an error in my records?
The patient can write an “Addendum” to be placed in his or her medical file. The original information will not be removed, but the new information, signed and dated by the patient, will be placed in the file. Health and Safety Code section 123111 states that an adult patient “shall have the right to provide to the health care provider a written addendum with respect to any item or statement in his or her records that the patient believes to be incomplete or incorrect. The addendum shall be limited to 250 words per alleged incomplete or incorrect item in the patient’s record and shall clearly indicate in writing that the patient wishes the addendum to be made a part of his or her record. The health care provider shall attach the addendum to the patient’s records and shall include that addendum whenever the health care provider makes a disclosure of the allegedly incomplete or incorrect portion of the patient’s records to any third party.”
Who owns medical records? Do the records belong to me?
No, they do not belong to the patient. Medical records are the property of the medical provider (or facility) that prepares them. This includes films and tracings from diagnostic imaging procedures such as x-ray, CT, PET, MRI, ultrasound, etc. The patient has a right to view the originals, and to obtain copies under Health and Safety Code sections 123100 – 123149.5.
Do x-ray films belong to me?
No, just like any other medical records, diagnostic films and tracings belong to the physician’s office or facility where they were made. The fees you paid for the x-rays or other diagnostic imaging were for the expertise, equipment, and supplies to take the images and diagnose them. You have a right to obtain copies of your films if you make a written request that they be provided directly to you and not to anyone else. The physician can charge you the actual cost of making the copies of the films.
How do I get my medical records transferred to my new doctor?
Transferring records between providers is considered a “professional courtesy” and is not covered by law. Most physicians do not charge a fee for transferring records, but the law does not govern this practice so there is nothing to preclude them from charging a copying fee. There is also no time limit on transferring records. You might wish to contact your local medical society to see if it has developed any guidelines on medical record transfer issues.
Can a doctor charge to send a copy of my records to another doctor?
Most physicians do not charge a fee for transferring records, but the law does not govern this practice so there is nothing to preclude them from charging a copying or transfer fee. There is also no time limit for record transfers, or no penalty for failure to transfer the records, since this is a professional courtesy. You might wish to contact your local medical society to see if it has developed any guidelines on record transfer issues.