Medical Records and Privacy in Iowa
by: Iowa Legal Aid
October 2003
When you go to the doctor or a hospital, the doctor or nurse always writes in your chart. This is part of your medical record. A medical record is a written history of the care a patient gets.
What Is In Your Medical Record
A medical record has several things in it. Doctors usually want some background information about their patient. This can include some nonmedical information about the patient, and a past medical history for the patient and patient's family.
The doctor keeps track of any medical complaints the patient has. Physical exam, lab work, or x-rays becomes part of the record. When the doctor decides what medical problem the patient has, the doctor writes it in the medical record. The doctor also needs to write down any treatment or drugs prescribed, and results of that treatment.
Once a patient starts a treatment, the medical record should include any progress the patient shows. It should also contain changes in therapy or medications. A doctor may also record a patient's failure to show for appointments or if the patient doesn't follow through with prescribed treatment. The medical record should also include telephone calls to and from the patient, and letters with second opinions and consultations from other providers.
What Happens to Medical Records
You may wonder how a doctor or hospital knows what to do with their medical records. A number of laws apply. Those laws include the constitution, federal and state statutes and regulations, and cases decided by judges. Doctors and hospitals also have their own policies and procedures. The American Medical Association (AMA) publishes ethical opinions which are enforced by the Iowa Board of Medical Examiners.
Medical records should not be changed. If a mistake is made in a medical record, a line may be drawn through the mistake, and the doctor or nurse may initial above the line and write "error." If a doctor dictates notes for someone else to type, the doctor should read the typed notes to make sure there are no errors.
Medical records are owned by the doctor or hospital. They are not the patient's property. But sometimes the patient may need to have copies of the records. The patient must be allowed to either review or have copies of the medical records unless that access could cause a danger to the patient or others. If there would be a danger, then the patient should be given a summary of what is in the medical records.
Doctors or hospitals can charge the patient for copies of medical records. Both the AMA and Iowa law say that the charge must be "reasonable." The Iowa Board of Medical Examiners has been talking about defining what reasonable means. If they decide that a doctor or hospital is charging too much for copies, they can discipline the doctor or hospital. The doctor or hospital may not deny or delay access to medical records if the patient owes money to the doctor or hospital for bills.
Confidentiality
You have probably heard that medical records are confidential. This means not just anyone can look at them. If you have ever wanted someone to be able to look at your medical records, you probably had to sign a release. Releases are only good for a limited time so you may need to sign another release. Mental health, HIV, and substance abuse records have special protections, so you need to check off an extra box on the release and maybe sign in a different area if you want those records released.
HIPAA
You may have noticed recently that you have to sign papers about privacy when you go to the doctor. This is due to some federal regulations called "HIPAA." This stands for Health Insurance Portability and Accountability Act. HIPAA was originally meant to deal with electronic commerce, but ended up affecting other areas, including health care.
Doctors and hospitals can get into trouble for violating HIPAA regulations. HIPAA privacy rules give people rights to access their medical records. HIPAA protects patients and people whose insurance is from a group health insurance plan. Health insurance plans through an employer, insurance carriers, and providers such as physicians, hospitals, and clinics have to follow these rules. Pharmacies must also follow the rules. They apply to some social service agencies, too.
HIPAA gives patients certain rights. First of all, the patient has the right to get a copy of the doctor's or hospital's Notice of Privacy Practices. The patient also has the right to access and copy the patient's protected medical records. The patient can also ask the doctor or hospital not to release medical information to certain people or organizations. The patient can also ask the doctor or hospital to add things to or correct their medical records. Finally, the patient also has the right to find out who has received copies of their medical records.
For details on HIPAA, you can look at the website www.iowasnip.org.
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