e. Third-Party Access Authorized By The Patient. Patients may also
authorize access to persons outside the medical community, e.g., insurance companies,
lawyers, family members. All patient authorizations for release of medical information to
a third party must be in writing. When medical information is officially required for uses
other than patient care, only enough information to satisfy the request should be
released.
f. Patient Access. Competent patients can generally authorize their own
access to medical records concerning their care. Since records contain technical
information, and many abbreviations and specialized terms, it is better for the patient to
review the record with someone who can provide clarification, as required. The
American Hospital Association also recommends that the attending physician be
notified before the records are released, and many hospitals follow this practice. It is
preferable, if the patient is willing, to have him or her accept information from the
physician, rather than having the patient read the medical record. But, if the patient
should wish to see the record, prompt and courteous access should be provided.
(1) The patient's motivations. If the patient feels a need to review his or her
own record, the staff should cooperate. A review of the record can provide needed
reassurance for a patient. It can satisfy curiosity and allay misgivings that there might
be a cover-up or that information is being withheld. It can defuse a hostile provider-
patient relationship and avert a decision on the part of the patient to hire an attorney or
file suit to obtain the records.
(2) Patient reactions. The patient may have negative reactions to the
contents of his or her records. He or she may become angered at seeing self-induced
or fictitious illnesses identified as such or suspicions of a physician's lack of sympathy
confirmed. Many patients are worried about their prognosis, fearing that the physician
may not be telling them the true severity of their illness. In the latter instance, seeing
the record provides the reassurance that they have been told all there is to know.
3-17. MEDICAL RECORDS IN THE RADIOLOGY DEPARTMENT
a. The Importance of Consulting the Medical Record. It is critical that the
radiographer review the patient's history before commencing any examination. The
records should be checked before beginning any contrast or special study. The nurse
should have completed an x-ray requisition, to include the patient's medical history so
that the radiology department can proceed based upon a full knowledge of the patient's
medical history. When this information is unavailable or disregarded the results can be
disastrous.
b. If the Records Are Unavailable. Theoretically, patients who come for a
contrast study will have their record with them. But, in fact, there are many times when
the patient will appear empty-handed. This is why it is essential for the radiographer to
ask the patient certain questions about his or her medical history before proceeding.
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