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Reading Hospital Records For Follow-Up Care

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A patient from the family physician medical office where you work was sent to see a gynecologist for abnormal uterine bleeding. The patient has now called your office requesting an appointment. She said that the gynecologist admitted her to the hospital, performed surgery, and said she should follow up with her own physician.

Instructions

You need to obtain the hospitalization medical records for this patient. Describe the relevant components of the medical record you expect the family physician will want to see. Provide a sequenced overview of what documentation you would expect to see on these components.

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Solution Summary

The solution includes a discussion on what documents are necessary to have for a patient's follow up care after a hospitalization and why they are necessary. 548 words with a reference.

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The HIPAA privacy rule allows for disclosure of protected health information for treatment without need of a release form (HIPAA, 2003).

1) Call the department of medical records at the hospital and ask the procedure to obtain the medical records of your patient.
It will usually involve a fax request with the complete name of the patient, date of birth, any other data requested for identification by the hospital and specific dates of hospitalization.

2) In your request it is important to include especially the documents or relevant components of the medical record you need to have. Since this is a follow up after surgery for abnormal bleeding the most relevant components of the medical records indispensable for the family physician are:
a) any laboratory reports ...

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