Medical Records | Arthritis Information

Hello all,
I am new here, diagnosed with RA last June. I have read many of the posts and am appreciative of all the insight, encouragement and help. I want to "give back" and share some of my knowledge regarding your health information. I am college instructor and have worked as a health data analyst and a director of Medical Records in hospitals. I hope some of the basics (at least in the US) can help you.

You own any health information about yourself
The facility or the physician owns the actual chart (or other storage media)
Any information that is to be used for your treatment or to pay for your care is required to be sent on at no charge
You can be charged if you request copies for yourself (but if you ask at the time of the visit, many offices and hospitals won't)
I highly recommend you start your own health record that you keep with you or available via the web
I am posting a link from the American Health Information Management Association (AHIMA) that give excellent advice on how to do it.
There are even FREE internet tools you can use to begin

I use a password protected web based medication list that I can access from anywhere I can use the web. I can update my med list, add food and drug allergies and more. Great for the numberous doctor, dentist etc. visits we make.

Many medical decisions are based on the information in your records. Doctors rarely call each other, just review the notes. I hope this helps
Mary B. Registered Health Information Technician and Certified Coding Specialist

http://www.myphr.com/your_record/index.asp

I keep an updated med list just in my computer and print it out when I go to the doc. I was just hospitalized and gave it to the ER docs and nurses and they loved it.

A web based health record is an excellent idea and I am going to do that. Thanks for the link!

Thank you for the information.

What about X-Rays? If the patient wants them can they keep them?

Wonderful advice!Yea you should just be able to call the drs office or hospital and request a copy of your xrays and any other diagnostic testing.Great info, Mary. I keep all my records in the computer. Diagnoses and dates diagnosed, on going care, all current medications, name, address and telephone numbers of doctors. Also, have doctor's offices copy lab work and any radiology reports. Since we travel 8 months of the year I'm very careful about keeping track of all medical info in case I need to be admitted or become ill in a foreign country or out of state. I've had to use my medical info several times in the last couple of years and it' really helped, especially when I was admitted to a hospital in another state. Thanks for posting. Hello,
You can get the Diagnostic Imaging reports and usually the films. When I had an MRI they just put it on a disc for my surgeon and made me a copy too. Also, I have noticed that people have posted that there are errors in their medical records. Per the Health Insurance Portability and Accountability Act (HIPAA) the patient is able to ask for an "amendment" to the record. Even if the physician does not agree to change the record, you can still "correct" the report by asking to add to it. You must do this in writing and it becomes part of your record.

Here is another great website to educate ourselves as consumers of health care. Many people do not even know they have the right to correct mistakes in their health record! Remember, you OWN the information. I make all my students visit this site for information (they are training to be future medical assistants, Health Unit Coordinator, Medical Secretaries and Health Data Analysts)

www.healthprivacy.org
Great information. How would I find my 'records' on the WEB? Do I need to sign up for a service? Does the Dr submit the information? Thank you for helping. SarahFor the records on the web there are several options. If the physician or facility has the capabilities they can send them to you electronically. If you have the actual paper document you can "scan" it into your computer. Or you can take the information from your actual records and record the information yourself and update as needed. If your diagnostic images are on a disc, you can save them to your computer. The benefit of having a web based record is that if you are like me, I often forget to take my physical records with me. If I am at work and realize that I can access them via the web or the physician/hospital can do it. It is your Personal Health Record and it is a small step to taking control of your diseases and care. It is so frustrating to go to a specialist and then be told they don't have your information. Or worse that the information is incorrect.

Mary - thank you for some positive, refreshing, pro-active ideas for helping us fellow sufferers in here. I finally threw all my records in the trash a few years ago when I gave up after years of not being believed, despite scientific blood tests showing a problem. Tomorrow, I am changing primaries once again, despite a specific letter of my permission to communicate with my rheumatologist about my skyrocketing thyroid numbers, which he either forgot or refused to do. Plus he had the wrong chart last time I was in and I finally figured it out after he asked about how I was doing on four medications I had never heard of before, but I digress. Oh, and the nurse called in the wrong dosage of the thyroid med, and after two weeks of going down hill I finally looked closely at the dosage amount and realized the error. Oh joy, and I pay them for this great privilege.

I started over, and slowly have built a "health resume" on my own, just hitting the high points, because the MDs only have ten minutes to see you, but plenty of time to meet the pharma reps.

I am a former elected official and legal secretary specializing in administrative law, and I sure would like to see some health care reform happen. Fourteen years since that piece of sausage that then-private citizen Hilary Clinton put on the table to start the debate, and no one in DC has the guts (because we hate HC) to pick it up and start making America healthy again. It's enough to make a sick person sick.

Best of luck with your autoimmune journey and please don't stop posting your great links and suggestions. Take care ~~ Cathy

I have heard FL is hard place to get good health care at times. You would think that with all the retirees down there it would be different.

Health care reform would be great! That is one of the issues that my husbands union concentrates on and supports. They have made a little headway with it but not much. I will dig up the article I just read in his union magazine and scan it when I have some quiet time. Have oldest daughter and grandbaby arriving for the week today! Time??? What is that?? LOL!!! cathy I just posted an article about what the general public feel what they would do for health care reform and guarenteed health care for everyone.

This information is an enormous help for me! Thank you so much! Much of my medical documentation from years ago is very misleading and is not accurate;dunno if it was the busy RD or his staff that goofed it so badly.

I will attempt the link you have also suggested, this sounds like a great way to keep all medical records in order.

jode

Question:

My RD sent my medical records for my PCP here in Michigan, but I gave that record to my PCP ( actually several hundred pages!). I am not so sure that my PCP has it anymore. DO I request another copy from my RD and agree to pay for the copy? WIll they send that to my home address?

jode

Grammaskittles - you will have to direct me to that link, because I cannot find it :) And Flor-e-duh is ripe for poor medicine because of what is known as "patient dumping". It's been headline news here lately, so it can be googled under news if you want more information.

Here's how the scam works and MDs are allowed to get away with it: 1) an aging population; 2) a fast growing population of newcomers fleeing the Northern states; 3) you get a new patient and send them on a round of testing with "specialists" who are all your friends
"aka kickback"; 4) patient come back and all the tests are "normal" so there is nothing wrong with them; 5) a returning patient cannot get any more money to made off of, so you "patient dump them" or dismiss them with a formal letter, then replace them with the thousands waiting in line as "new patients", which the insurance companies will pay more for, and you send them out again to your friends for tests. Nobody bothers to read the results, or put two and two together, OR SEND YOU TO THE RIGHT SPECIALIST IN THE FIRST PLACE TOO FAST BECAUSE YOU GOTTA GET YOUR FRIENDS PAID FIRST, so you are "dumped" and replaced with a new patient to start to be able to charge the higher priced new patient fees again. It's well documented, and legal, and I have heard rumors its openly 'taught" in medical schools now. I love America. Cathy

justsaynoemore39201.7748148148

Cathy dahlin...there is no link to the article. I have to type it up and post it. I am going to do that tomorrow morning when I don't have the 3 girls and the grandbaby chattering in my ear and I can concentrate lol.

Nice scam. Un-freakin-believable. Isn't it just great how we as valuable human beings are treated. URG!!!

Hello again,

Jodejjr,
Good questions! Your PCP may still have the original, but more than likely you will have to contact your RD for copies. They can charge you if it doesn't go directly to physician. You may ask for "parts" of the record though. You may request you initial History and Physical, labs etc and the information from the last visit. Depending on where youlive the charges vary. I have posted here the regulations for Washington state. As you can see it can add up to quite a bit.

Unfortunately, what justsaynoemore is true. The CPT code for "new" patients pays more than for established patients. I am a nationally certified coding specialist and I teach it for a living. I make very sure my students know if they are asked to "upcode" for financial gain, they too will be held accountable, not just the physician. The office staff puts the codes on the bill and submits them. I also teach a legal and ethical medical office course, and I always give them a "what if" situation with the billing and coding. What would you do if you were asked to "upcode" or submit untrue information. It is a FEDERAL crime if they do this to Medicare/Medicaid. I hope at least my students will draw the line if they are asked to do this.

There will be times that there is an honest mistake with the coding and billing. Some physician take a weekend course on how to "improve" their coding and reimbursement and they don't even realize they are doing it incorrectly. I look my bill over with a fine tooth comb, but how many people can or will do that? I made sure to ask for the diagnostic codes for my husband when he had chest pain that turned out to be a potassium deficiency. It does make a difference in the long run when you apply for insurance later on.

How much can a medical provider charge for searching and duplicating medical records?  RCW 70.02.010(12) allows medical providers to charge fees for searching and duplicating medical records. The fees a provider may charge cannot exceed the fees listed below:

     (1) Copying charge per page:

     (a) No more than ninety-one cents per page for the first thirty pages;

     (b) No more than sixty-nine cents per page for all other pages.

Yay! You are a wealth of invaluable information! Thank you so much for all of this info.

Can you find the diagnostic codes on the internet at all? I wouldn't even know where to begin to look for them lol.

Hello again,
Yes you can find them at the link below. They are maintained by the feds so they are available, but this site makes them easy to find. You can search by words (make sure your spelling is correct) or if you see a number on your lab request or records you can enter them in and it will bring up the disease. 714.0 is RA and there are other codes that describe the possible complications of RA. Coding is actually quite a complex procedure (just ask my students who took a test today) due to the rules, guidelines and payer conditions.

Sometimes, if the code is incorrect the insurance company will refuse to pay for tests and such. The physician and hospitals are reimbursed based on these codes and the CPT codes (for procedures).

I am happy to help with any medical records questions.

www.icd9coding.com

Mary B.

Well I am going to go with the assumption that my RD has staff members that made mistakes. I will need him for accuracy with my health and he has always been very accurate with my health and I do not want any hard feelings. I drive a long distance to see him and he knows my case and what has worked and what hasn't so it is worth it to me rather than trying to find a new RD and begin again. I am so weary of "begin again". Must be my age huh? *grin*

The info is invaluable and much appreciated. Thank you for coming forward with that and sharing it with everyone.

jode