Step

Action

1

Have the patient or surrogate fill out an Access to Open Record Request and send it to the Privacy Officer.

2

If a surrogate is making the request, secure copies of any document(s) authorizing the surrogate to act on the patient's behalf. These must be attached to the original request.

3

The Privacy Officer documents the request and calculates the 15-day deadline for the response, noting it on all copies of the form.

4

The Privacy Officer then:

Copies the request

Forwards the original request to the patient's attending physician, or to the cover physician as soon as possible but no later than 72 hours after receiving the written request.

Step

Action

1

Determines whether disclosing all or part of the medical record would be harmful to the patient's physical, mental or emotional health.

2

3

If the physician's professional judgement is that access to the records would not be harmful to the patient's physical, mental or emotional health, proceed as follows:

If the information is... Then... Unavailable, for example: Cannot be retrieved within 15 days Relates to research and may not be disclosed The physician completes the response section of the Access to Open Record Request explaining why the records are unavailable The physician returns the form to the Privacy Officer Available, the physician sends the form to the Privacy Officer The Nurse Manager and Privacy Officer arrange a reasonable time and place for the patient to view the medical record in the presence of the Nurse Manager or designee If the patient has requested copies, a staff member copies the requested information charging a fee (if appropriate) established by Health Information Management (HIM) Non-existent or cannot be found, the physician sends the form to the Privacy Officer, go to Step 4 The Privacy Officer informs the patient in writing

4

The physician returns the complete access form to the Privacy Officer within a reasonable time, not to exceed seven calendar days.

5

6

The Privacy Officer must (no later than 13 calendar days after the patient's written request) hand-deliver a copy of the completed request to the patient if the patient is still in the hospital.

If the request has been denied, the Privacy Officer sends a Denial of Access to Medical Records letter explaining the right to appeal the denial

If the patient is discharged before the request is considered, UTHCPC follows through and responds to the request no later than the original deadline, as determined in Request to See Open Record, Step 3.

7

If the patient appeals a denial (in whole or in part) of access, the Privacy Officer forwards the denial to the Chair of the Medical Records Committee.

8

The Chair of the Medical Records Committee reviews the decision to deny access using the "best clinical judgement" standard, sending the response to the Privacy Officer within 7 calendar days but as soon as practicable.

9

Follow the procedure outlined in Response, Steps 1-4.