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  • 1.  Denying patient records?

    Posted 08-10-2022 12:29 PM

    Looking for some guidance on releasing medical records to patients. Our Medical Director has requested to put the following statement in our Records Release policy. 

    "Access to all or part of a record may be denied, upon exercise of professional judgment of the Director of Clinical Services when such access is judged to be reasonably likely to endanger the life or physical safety of the individual or another person. A note will be placed in the client's record as to what cannot be released in the judgment of the Director."

    I am not in favor of this statement as I feel it will slow down our release process as well as could cause some issues with HIPAA. It is my interpretation of HIPAA regulations that we can deny parts of the record if a clinician determines that releasing the records could cause harm to the patient however this determination needs to happen at the time of service. If you have a statement like this in your current record release policy could you share your rationale with me? If you do not have this statement and release all records to patients can you explain why you release all records? I am open to any other feedback as I am new to the compliance/HIPAA world. Thanks!

    Nicole Lewis
    Director of Quality & Compliance
    Southside Behavioral Health
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  • 2.  RE: Denying patient records?

    Posted 08-10-2022 12:39 PM
    Hi Nicole,

    Funny timing on this as just yesterday I finalized the final draft to update our policy on this exact topic. This is a case of an appealable denial on behalf of the patient, so I would be sure to include that within your policy if it isn't already there. I just looked through the relevant regulation to see if there is any indication this determination must happen at the time of service but was unable to locate anything. See 45 CFR 164.524(a)(3).

    In the instance of this situation where a patient has the right to appeal, we lay out that patient must be notified within 30 days of the determination and include:
    1. the basis of denial;
    2. instructions on how to file a complaint; and
    3. their right to appeal the full or partial denial of access and how they can appeal - identifying that a licensed healthcare professional not involved with their care will review and their determination is final.

    Jonathan Sullivan, CHC
    Compliance Coordinator
    Cascade Health
    Eugene, OR

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  • 3.  RE: Denying patient records?

    Posted 08-11-2022 08:02 AM
    I'd suggest taking a look at the reg. There are legitimate reasons to deny access. Cures Act Final Rule: Information Blocking Exceptions (healthit.gov)

    Brenda Manning JD, CHC, CHPC
    Privacy Counsel
    Maximus, Inc.

    The views expressed herein are my own and do not represent those of my employer. They are not meant to constitute legal advice or create an attorney-client relationship.

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  • 4.  RE: Denying patient records?

    Posted 08-10-2022 01:27 PM
    The only reason that my company denies access to a medical record is if it contains psychotherapy notes. Our mental health providers make the decision, not the Director of our facilities. The psychotherapy notes should be separated from the rest of the medical record.


    Patrick Forand, MPH, CHPC
    Senior Director of Compliance
    CAN Community Health
    Sarasota, Florida

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  • 5.  RE: Denying patient records?

    Posted 08-10-2022 02:55 PM
      |   view attached


    We have an entire policy about it, LOL!  I attached a sanitized version, along with a form we use to notify the patient.



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