UTMB HANDBOOK OF OPERATING PROCEDURES

Section 9 Clinical Policies Subject 9.2 Patient Records Policy 9.2.6 Medical Record Access

12/01/90 - Originated 04/06/09 - Reviewed w/ changes Reviewed w/o changes Health Information Management - Author

Medical Record Access

Policy

The medical record should be readily available to all practitioners who encounter the patient on either a scheduled or a non-scheduled (i.e., emergency) basis. Access to the medical record is to be restricted to only those individuals who have a legitimate need to know for use in the normal course of business. It is the legal responsibility of all UTMB employees and students to protect the confidentiality of the information within the record. . Medical records needed for direct patient care purposes are requested by the area treating the patient (e.g. the clinic, inpatient floor, emergency department).When an individual requestor needs a medical record for purposes other than patient care (i.e. payment, healthcare operations, or research), the Health Information Management (HIM) Department is contacted for access to the paper medical record. Access to the paper medical record will be granted to those who provide a valid UTMB ID badge and/or appropriate documentation to access the information. Access to the electronic medical record will be provided to those who have been authorized by their department's trusted requestor via the [IRAM] process and have completed the appropriate Epic training class based on their role. . All medical records are the property of the University of Texas Medical Branch Hospitals and Clinics and shall not be removed from the premises of the University of Texas Medical Branch Hospitals and Clinics except in accordance with a court order or subpoena. As a general rule all authorized requestors may keep the record until 5:00pm the same day as received, and then must return records to the HIM Department. Records of deceased patients are the exception. If a requesting party does not return all records to the HIM Department by the end of the day received, no additional records will be released to that party until all overdue records are returned. Records shall not be sequestered in places such as lockers or desks or in any other way made unavailable for immediate access. Individuals who violate this policy are subject to appropriate disciplinary action up to and including termination.

Medical Record Access Process

For purposes of treatment, payment and healthcare operations (TPO), access to the medical record must be approved by the Department Chairman, Director, or Executive Director, and HIM. Requestors must request access by submitting an Application to Request Medical Records form to HIM. Once HIM has approved access, the requestor will be notified of the approval and their assigned requestor code number. For research purposes, the research requestor must submit a UTMB Request for Patient Data form to HIM. The HIM Research coordinator will contact the research requestor with their research number. Medical records must be reviewed in the HIM research area and cannot be removed from this area. Incomplete medical records will not be checked out but are available for review in the Record Processing Section of the HIM Department

Record Return Requirements

As a general rule: Inpatient Nursing Units shall keep records until 6:00 a.m., of the day following patient discharge. Following discharge, records go to the Record Processing Section of the HIM Department. Outpatient treatment areas must return records the same day as the patient's visit. Following an autopsy, records must be returned to Record Processing Section within three (3) working days of autopsy. When a record is signed out of the HIM Department and is needed for direct patient care, the area or person in possession of the medical record must make the record available to HIM. Failure to comply with these return requirements could result in loss of record check-out privileges. If a medical record is needed for an extended period of time, a special request must be approved by the HIM Department's director or designee.

Medical Record Transfer Process

If an approved medical record requestor transfers a record to another location, it is his/her responsibility to notify the HIM Department of the new location of the record. The requestor will continue to be charged with having possession of the record until the HIM Department receives this notice.

References

Institutional Handbook of Operating Procedures Policies: 2.1.3 Release of Information Under the Texas Public Records Act 9.2.1, Obligations of the Management of UTMB’s Protected Health Information (PHI) 9.2.13, UTMB Medical Record Policy