Can I Look at Mom’s Chart?

By Marc Belcastro, DO, system chief medical officer, Premier Health

As physicians and Advanced Practice Providers, we want to be there for our family and friends, and they desire us to walk with them through the stressful times of a hospitalization. They often plead with us to “take a look” to make sure everything looks OK or help explain test results. What parent does not want their son or daughter to understand all aspects of their care in order to provide comfort and assurance and explain this sea of information?

Is verbal permission sufficient to open a patient’s chart if you are not part of their treatment team or acting as a health care provider for them in another setting? It certainly “feels” like this should be fine. After all, we are professionals, and we understand medicine and health care privacy. However, it is not only not OK; it is a violation of the Health Insurance Portability and Accountability Act (HIPAA) that can carry significant financial consequences for both the individual provider as well as the hospital.

Then how can we obtain information to support our family and friends when asked? We can go to our local Health Information Management Office (formerly called Medical Records) and request a release of information form. This form must be signed by the patient after the information is filled in specifying us as having permission to open the medical record. This form can be given to the patient’s nurse or the health unit coordinator. After discharge, it will be scanned into the patient’s electronic chart. The most important part of this process is to remember that the form is only good for 30 days and must be renewed after that time.

If you ever have questions or need guidance, feel free to reach out to me or your local chief medical officer. We are happy to help you. We understand and want to keep you safe. We experience these same requests from family and friends.

Back to the February 2022 issue of Premier Pulse