TCO7
Given a request for patient information, correctly apply confidentiality laws, regulations, and policies in order to process and release appropriate information.
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Release of Information (ROI)
When asking about ROI at Orchard Park, I learned that the requestor, who must either be the patient or Power of Attorney (PoA), has to fill out the Authorization for the Release of Clinical Information sheet. They turn that into Dianne, Director of Medical Records, who then fills out a memo to request the information and sends it to the facility attorney. If the requesters are released the information, they have to pay $.25 for each page of the medical record they request.
Authorization of release filled out by patient or power of attorney.
This is the memo form completed by medical records to send to the facility attorney, requesting the release of information.
Dianne shared some additional rules regarding the medical record:
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First and foremost, HIPAA compliance for the Privacy of the Patient. Records can only be released to the patient or guardian of the patient, or Power of Attorney.
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The goal is to maintain correctness and make sure the information in the record is as accurate as possible.
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Documentation of complete records that give an accurate representation/overview of the patient’s stay.
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Employees can’t tell people on the phone if any particular patient is being treated there.
**Most of the ROI requests actually come from insurance companies that want proof that the patient required the services that they are being charged for. The facility received a couple of insurance company requests while I was there. They called them "audits." So basically, Dianne had to fax the entire record to the insurance company. If there is not enough proof for the claims, they can be denied and the facility will have to absorb the costs. Occasionally, patients or relatives will request information, but that did not occur during the time I spent there.