Can I Look At My Hospital Chart? Can My Family?

A reader nurse asks me whether a patient or their family can look at their hospital medical chart while they are hospitalized:

Dear Happy, never actually had this happen but I had a patient's daughter (who is a nurse) ask to see her mother's chart (her mom said it was OK). Can she do this? Or can any patient do this? I didn't feel comfortable and said she would need a written release and should probably wait until the patient is discharged, as the chart is an original, etc. I think there was no malicious intent but who ever knows? Of course this was late at night and I wasn't in house, but I don't want to deny a legal right if indeed that is their right at that time. Thanks.

I occasionally get asked by nursing staff if it is OK for family to look at the chart.   I always say it's OK with me.   Honestly, I don't think getting the OK from the physician is even required.   As a potential patient or having family as potential patients, I would like to think I have a right to view what others are writing about me or my hospital situation.

 I have no idea what the legalities of it are of nonmedical staff reviewing the chart . I'm sure most hospitals have a written policy on patient and family requests for this issue.  If an RN says you can't, ask them if that is the hospital policy and ask them what statue in the policy says so.  More than likely, the RN doesn't know as most policies like this are rarely reviewed in their entirety.  Ask them for a copy of the written hospital policy on reviewing your own chart.  There should always be a "house supervisor" on site that can get you anything you need, 24 hours a day.

Perhaps the policy requires a medical professional to be with the chart while it is being reviewed to prevent alterations.  Perhaps it doesn't.   I don't know.    I figure, if someone is calling me to ask me the physician, I must have some say in the matter.  Although, I suspect I don't and that some hospital policy that was never reviewed by the RN says so.

I've never been taught what to do either.  I just say it's fine with me and let the RN handle it as per the hospital policy.   What are your experiences?  Do you let families look at the chart or tell them to wait until the chart has been finalized in medical records.

I'm not sure how HIPAA applies here, but keep in mind the following:

"HIPAA rules do not apply in bars.  If they did, any attempt at a social gathering among colleagues would result in awkward silence."

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11 Outbursts:

  1. I actually don't have this happen too often. In training, I was told that the family could do so, but had to be supervised in medical records. (I presume that was a paranoid hospital's policy).

    Since I've been a hospitalist, it's only happened once. But think about why they're asking. It's because they feel like they haven't been communicated with appropriately/sufficiently. I find that when I take over a service for the week, they're often right.

    My approach then is what I think it will be in the future. I take the chart into the room with me, sit down with it open, and ask then what I can help then with. It actually diffused the situation nicely.

    That said, this is going to be a harder request to fulfill since you can't exactly "log in" the family members to the EMR and let them rummage around... especially when we assume secretarial duties... I mean... when we go to physician order entry.

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  2. I will bloodydamnwell sue the shorts off anyone or any hospital that lets my family look at my chart without my permission.

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  3. I've seen this in two scenarios:

    most commonly it's a non-medical person who has no idea what they are looking at; it's being used as a control tactic against the patient or the docs (or both). Occasionally family will insist something be changed and will call administration over something they don't like. Usually it's an an overdose pt or someone admitted for panic attack that the family insists has a disease they don't. Sometimes it's family who plans a lawsuit (you have to say the weakness is from the acccident, not the cocaine induced stroke...)

    Other times it's a doc who is either distantly realted to the pt or a friend of the pt's relative. Family has no clue what is going on and hospitalists/consultants/nurses have tried to explain (or are to busy to explain) but family doesn't get it. Usually family is perseverating on something meaningless (number of IVs, pt needs foot cream while in ICU for MI, I think she needs new glasses..) In these cases I've read the pt's chart so I can spend the next few hours trying to explain to the family (my family...) what's really going on and what they need to do.

    Sometimes we can say things to our own relatives that the hospital staff is too professional to say. If one of the docs is able to talk to me, then I don't need to see the chart but it does make my aunt and uncle happy if I pretent to study it.

    When someone asks to see my patient's chart, I just ask "why?" - usually this solves the problem.

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  4. I think I have had one family ever year or so ask to read the chart. I also ask why and quickly review the chart for any undignified "chart wars" that may have occurred. This assessment is usually done in 5 minutes, and then I let the family look with the patient's permission. No one can read the progress notes, because the handwriting is so bad, and the family feels secure that there are no unnatural secrets occurring. Most are bored with the chart in a few minutes and give it back. I always want to review my parents' charts when they are admitted, just to make sure no one has missed anything important, because as doctor/daughter I consider myself part of a team focused on getting my parent well. Too much paranoia just makes you look guilty.

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  5. When our son was in the NICU we read his chart all the time. It was sitting out where this was easy to do. No one seemed to think this was unusual for a couple of educated but non-medical parents to be doing. I would have been upset if this had not been permitted.

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  6. We let families read the charts if the patient gives permission. I see absolutely no problem with this. We make sure their doctor or nurse is available to answer any questions.

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  7. The chart can be viewed with permission of the patient. It is viewable after discharge anyway as well so what ever is in there prior to discharge is in there after discharge...legal and binding. Its the permission part that is the sticky area....be sure the patient is alert and in the right state of mind. I would make sure the hospital has or does not have a release form policy for viewing the chart prior to discharge. When I worked on the floor no one ever asked about viewing the chart...I think it is a 'fear' of crossing the line for most folks.

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  8. Agree with refugee. I go over it with them.

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  9. Are you really a Doctor??? Thats one of the most stupid things you can ever do... You could put on a clown nose and some big shoes, but that wouldn't be quite as bad...Ever heard of HIPPA??? Maybe the patient doesn't want his wife knowin about that case of GC he had in 1982, or his positive drug screen or maybe its the wife who's blood typeo , he's AB, and the new baby is "O"...DOH!!!!!!
    Its a bad idea, but someones gotta do it,

    Frank

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  10. Seriously?!
    Since some of ya are OK with tossing $$ away... can you toss some my way?...just say'n.
    -Second career nursing student

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  11. @Frank, it's HIPAA... (sorry a pet peeve of mine)

    The hospital where I work limits access to charts to only those people for which a valid signed release exists. You are not allowed to enter your own chart (or you will be terminated) on your own. You must sign a release and the requested information will be released through the medical records department to you.

    Frankly, most of the responses above where family are allowed to browse through a chart would get you canned at our place.

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