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Fam Pract Manag. 2002 Jun;9(6):61.

Patient refusal to release records

Q

If a patient refuses to consent to the release of his or her medical records, should I tell the person requesting the records that the patient has refused to release them?

No. As a general rule, you should not contact the records requestor to indicate that the patient has refused to release his or her records. In some cases, such as a records request by an employer, telling the requestor that the patient has refused to release his or her medical records may be taken as an indication from you that a problem exists. Furthermore, when a patient has not consented to the release of any information to the requestor, even acknowledging that the individual is a patient of yours or the practice is a breach of confidentiality.

In this type of situation, you should first try to obtain consent from the patient to acknowledge that he or she is a patient of yours or the practice. If the patient consents to this, you should do one of two things:

  • Send a letter to the requestor enclosing the appropriately authorized sections of the record, noting that all medical records consistent with the patient's authorization for release, and applicable law, are enclosed.

  • Send a letter to the requestor noting that appropriate consent for the release of information has not been supplied; therefore, no records are enclosed.

If the patient does not consent to you acknowledging that he or she is a patient of yours or the practice, you should inform the requestor that he or she has requested individually identifiable health information that is confidential under federal and state law, that you cannot disclose whether the patient belongs to your practice and that no further information can be supplied.

Documentation shortcuts

Q

How can I find or create computerized macros or templates to decrease my dictating and transcribing time?

Computerized macros and templates are excellent timesaving tools. For example, using a macro, you could simply type a few keystrokes to input an entire paragraph of standardized text into an encounter note template. Most commercial electronic medical record (EMR) systems come with modifiable templates and macros and have active user groups that share customized versions. However, if you don't have or aren't planning on purchasing a commercial EMR, there is a free EMR system that allows the creation of chart notes using templates and macros on the Internet (EZChart, www.ezmedicaloffice.com). Also, you might consider creating a word-processing-based EMR, as I have done, that allows you to create macros and templates using Microsoft Word (see “Electronic Paper & Pencil: 6 Easy Steps to a Low-Cost Electronic Medical Record,” FPM, May 2001, page 33).

Another option for creating macros is to download Shorthand for Windows (www65.pair.com/lim/shorthand; $89; free 30-day trial available). To use Shorthand, you will first need to create encounter note templates for conditions you see regularly (e.g., low-back pain, headache, cough and asthma). You can do this within any Windows-based program (such as Microsoft Word), or you can copy templates that other physicians have already created (e-mail me at jack.jue@ucdmc.ucdavis.edu to try some of my templates). The Shorthand program then allows you to insert data into your encounter note template with just a click of the mouse.

Bonus formula

Q

My partner and I are in the process of hiring physicians to staff several local urgent care centers we own. We currently pay a generous hourly wage, but we would also like to offer some type of bonus to encourage the physicians to commit to a long-term agreement. What kind of bonus formula would be simplest?

In your situation, the simplest bonus formula would be based on the number of patients a physician sees in a month. To figure this type of bonus, first calculate each physician's monthly break-even point, which is the number of patient visits it takes to cover the physician's wages, benefits and related overhead costs (e.g., staff, facility, supplies). For all patient visits above the break-even point, award the physician a bonus equal to 20 percent to 30 percent of the collected amount for those visits. This bonus formula encourages physicians to work those “extra” patients into their schedules.


 

Copyright © 2002 by the American Academy of Family Physicians.
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