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MRA Thought of the Day – Medical Record Redacting: A Burdensome and Problematic Method for Protecting Patient Privacy

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Situation:

Kathy Gordon, RHIA, Vice President of Release of Information

Kathy Gordon, RHIA, Vice President of Release of Information

A healthcare facility received a subpoena for a patient’s entire medical record. Upon review of the information, it was noted that the records contained legally protected information. The hospital responded by sending an objection letter which stated the requirement for a proper judicial order or the patient’s specific authorization in order to release the privileged information.

Upon receipt of the objection letter, the attorney contacted the HIM Department to argue that he was not interested in receiving the privileged information and wanted it to be left out. The medical record was extremely voluminous and it contained legally protected information throughout cheapest price viagra so it was not an option to even consider redacting the record in response to the attorney’s verbal request.

A few days later, a court order was received as a follow up to the subpoena. Based on the court order, any and all records were ordered to be released with the exception of those considered privileged under MGL c. 111 s. 70f and MGL c112 s.129A which is exactly the privileged information the health care facility was trying to protect.

Here are my thoughts…

In this instance, the records had to be redacted based on the specificity of the court order. When redaction is truly warranted, it is recommended that more than one person be involved in the process. As most of us are aware, privileged information is generally not limited to a specific report or listed in the discharge summary alone. In many cases, it can be referenced throughout the medical record.

In general, redacting is strongly discouraged due to the burdensome task it creates and the liability involved if any information is overlooked. However, when redacting is part of a court order or required under very special circumstances, the redaction must be clearly marked.

It is suggested that two people review the health information. One person should go through the medical record and redact the privileged information. The other should review the redacted material to confirm everything has been removed and the redacted information is unrecognizable prior to release.

What are your thoughts?

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