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Medical Records

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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The HIPAA privacy rule allows for disclosure of protected health information for treatment without need of a release form (HIPAA, 2003). To obtain hospital records you need to call the department of medical records in 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. You should also include the documents you are most interested to obtain. Otherwise, when you ask for hospital records, you may get administrative paper like admission ...

Solution Summary

The solution involves an explanation of which parts of a hospital medical record are essential for follow up care of a post-surgery patient by a family practice physician, what documents are not needed and how to obtain such documents.

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