Alliance for the Improvement of Maternity Services (AIMS)

 

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GETTING YOUR HOSPITAL/MEDICAL RECORDS

In the event of hospitalization, obtain and preserve a complete copy of your hospital medical records. If hospitalized for childbirth, also obtain and preserve a complete copy of your infant's hospital and medical records, including nursing notes, lab reports, brand name of fetal monitor (long-term effects of ultrasound are unknown), any x-rays, fetal monitor strip charts, etc. (Nursing notes include not only information recorded by nurses but also information recorded by other personnel caring for the patient.)

Check with your State Department of Health to see if your state provides for patient access to his or her hospital medical records, including nursing notes. If your state does not provide for such access click on YOUR RIGHT TO YOUR MEDICAL RECORDS, to see a copy of the New York law which could be introduced in your state legislature.

If you would like to obtain a copy of your hospital medical records, it is more effective to send the request in writing.  Send a letter (example below) to the chief administrator of the hospital.

To get his or her name call the hospital and ask for the "Administrator's Office". Tell the secretary that you would like to address a letter to the chief administrative officer and would like his or her name and official title. Such information is usually readily given.

Make several copies of the letter you send. Send a follow-up copy of your letter in two weeks if you have not received a reply.

If you have not received your medical records or a satisfactory reply within one month of sending the first letter you may choose to send the second, less friendly letter.




First Letter



Home address

Date

Chief Administrative Officer

_____________________Hospital

Town, State 00000

Dear __________________:

I hereby authorize the administration of ___________________ Hospital to release directly to me a copy of my and my baby's complete hospital medical records, including nursing notes, pertaining to our stay in __________ Hospital from (date) to (date). I will pay an appropriate fee for the reproduction of our records and for first class postage.

I realize that the physical records belong to the hospital; however, I am aware that the information contained in our records belongs to me. I therefore authorize the administration of _________Hospital to send a complete copy of my and my baby's records, including nursing notes, directly to me, not to my doctor. I wish to maintain a copy of my and my baby's complete hospital medical records in my own files and would appreciate a friendly compliance with my request.

Sincerely yours,






Second Letter



Home Address

Date

Chief Administrative Officer

 _____________________Hospital

Town, State 00000

Dear __________________:

In my letter of (date) (see enclosed copy) I requested that you release directly to me a copy of my and my baby's complete hospital medical records, including nursing notes, pertaining to our stay in __________________ Hospital from (date) to (date).

I have authorized the release of our records directly to me (not to my doctor) and have offered to pay an appropriate fee for their reproduction and mailing by first class mail. Your refusal to comply with my request indicates either that you and your hospital have something to hide or that I have not stated my authorization properly. If the latter is the cause for the delay, I would appreciate your advising me as to the proper procedure for securing the records I have requested.

If I do not receive a complete copy of our hospital medical records (I do not wish a summary or abstract) within two weeks then you will force me to bring legal action against the hospital to obtain our records.

It would be foolish indeed if the hospital forces me to take legal action when mere compliance with my request would solve the problem in an amicable way.

Sincerely yours,






In the event that the hospital proposes to charge you more than 50 cents a page ask the hospital's Medical Record Administrator what the copying charge is per page when hospital records are requested by a physician. There is no justification for the charges to be different -- a patient's retention of a copy of his or her hospital records insures continuity of care. If the hospital persists in charging you a higher rate, contact your local newspaper's health editor and suggest that the newspaper publicize this obvious effort to place obstacles in the way of patients' access to their own medical records.