MRA Thought of the Day–Interpretation of a Medical Record

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Nilda Tamburello RHIA, Vice President of Release Of Information

Nilda Tamburello RHIA, Vice President of Release Of Information

A request was received from an attorney’s office requesting a copy of his client’s medical record. The request was processed in its usual manner and sent to the attorney.Upon reviewing the copies of his client’s medical record, the attorney could not read a particular name of a nurse who had documented in the nurses notes. The HIM department’s release of information desk received a call from the attorney requesting interpretation of the name of the nurse.

My Thoughts:

  • Risk Management should be notified and they should contact the attorney to discuss how to resolve the issue.
  • If appropriate, Risk Management would then contact the hospital’s General Counsel.
  • Invite the attorney to review the original medical record within the HIM department; and stay with the attorney should additional questions arise. However, Release of Information (ROI) should NOT interpret any part of the medical record.
  • If possible, notify the patient’s physician with any additional questions.
  • In some hospitals a list can be provided of anyone that treated the patient.

What would you do?

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