The phrases medical record, health record, and medical chart are used interchangeably to represent the systematic documentation of a single patient’s medical history and care across time within the jurisdiction of a single health care provider.
How to Obtain Medical Records
To request your medical records, most clinics or facilities will want you to fill out a form. This request form is normally available in the office or can be sent through fax, postal service, or email.
If the office does not have a form, you can submit your request in writing. Include the following:
Your name
Social Security number
Date of birth
Phone number and address
Email address
The list of records that have been requested
The service dates
Delivery option (fax, post, email, in person)
Signature
You may have to wait a time after making the request before the records are received. State rules differ, but most mandate delivery within 30 to 60 days. Keep a copy of the original request and call your state’s Department of Health if you do not obtain the papers after several attempts.
Cost of Service
You should be aware that whether you want your medical records delivered on paper, via fax, or electronically, you may have to pay for them. While prices may vary, they must be reasonable.
Furthermore, you have the right access the records even if you haven’t paid the healthcare practitioner or institution for the service. The records cannot be withheld because of nonpayment, nor may you be charged an unreasonable fee to compensate for nonpayment of services. If money is owed, the healthcare practitioner or facility can use collection methods such as legal action or a debt collection service. Copies of Your Medical Records Costs
For a Healthcare Professional Who Is No Longer in Practice
If your healthcare professional retires or no longer practices, all medical records must be kept in accordance with the law. This is true even if a healthcare professional dies or closes his or her practice without selling it.
The medical records must be transferred to another healthcare provider who agrees to bear responsibility under the law.
If a suitable supplier cannot be found, the records can be archived with a reliable commercial storage company.
Error Correction
Examine your medical records carefully once you’ve acquired a copy. If you discover any errors or omissions, you should have them fixed as soon as possible to ensure that they do not jeopardize your future care.
The majority of providers will agree to repair factual errors or locate reports that should have been kept in your file.
Is it possible for a patient to request their own medical records? What about South Africa?
Access to medical records is included. Access can be requested by either the patient or someone authorized to act on the patient’s behalf; normally, the request is submitted in writing and should be responded to within 30 calendar days.
In South Africa, how long do hospitals store medical records?
9.4 Health records must be retained for 20 years following treatment under the Occupational Health and Safety Act (Act No. 85 of 1993).
