Records & Case Management
Management of Medical Records
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It’s common for a person to be in more than one hospital while recovering from brain injury. New providers always request medical records including names, addresses, phone numbers, and dates of service from all previous providers. Gathering this information can be frustrating to families who may be struggling with critical health issues for their loved one, but it is a necessary reality of the health care process.
Medical facilities have various names for departments that manage medical records such as: Information Systems, Management Systems, Information Management, Medical Records, etc.
The first rule of Management of Medical Records is: Request key medical documents immediately upon discharge from each facility or program.
These include:
- Admission history and physical summary
- Medical/Rehabilitation Evaluations
- Neuropsychological Evaluations
- Primary treating physician’s discharge summary
- Operative notes
Families should keep a copy of medical records for themselves. Also all treating physicians in the person’s medical/rehabilitation facility should be encouraged to send copies of their office notes to each other to assure continuity of care.
Legal Rights
Persons being treated or their legal representatives have a right to:
- See their records while being treated
- Have a copy of their complete records provided in a timely manner after discharge at no cost beyond copying (In-patient)
- Receive physician’s office notes and evaluation reports (Out-patient). Typically these are mailed out.
If the patient is of legal age but due to physical or cognitive impairments cannot sign for records, the facility may not release the records—even to a family member—without a legal document.
Costs of Medical Records
While facilities are not to charge for one copy of medical records, they may charge a fee if the request for documents is not made soon after discharge. There is a legitimate cost involved for administrators to retrieve old records versus current documents. The patient should also expect to be billed for additional copies. Many hospitals pay third parties to manage medical records after discharge. These outside agencies consistently charge for record copying and handling. Before requesting documents, ask about costs—they can be significant. If the patient or family has kept a medical records file, copying and sending out the documents themselves may be a better option.
Medical Release Forms
Patients or their legal representatives may need to sign a release of medical information before providing records to any party. Psychological testing and counseling records may require a specific authorization.
Organizing Records
Unless the person or family assumes responsibility for organizing medical records, valuable information can be lost requiring duplicate testing and/or evaluations. A log should be kept tracking the following:
- Name of facility, address and phone number
- Dates of admission and discharge
- Name, address and phone number of each medical team members by facility.
- Physician’s office notes and evaluation reports (Out-patient)
- Any phone calls made by the person or family to the facility or medical personnel
See About the Medical Records Notebook on this site for instructions on creating a comprehensive Medical Notebook
Brain injury is a long journey and medical information, though often requested, is easily forgotten. While tracking may seem non-essential at the moment, organizing medical records into a notebook or file can save a great deal of time and effort over the course of treatment.
Lu Rae Ahrendt is a certified rehabilitation nurse and certified case manager. She provides catastrophic case management services and life care plans for children and adults with disabilities and chronic illnesses and has extensive experience in the development, coordination and implementation of plans of care for individuals with brain injuries. Ms. Ahrendt presents to numerous professional and disability support organizations. She is a current board member and former board chairperson for the Brain Injury Resource Foundation.
Karen Moderow is a freelance writer with over ten years experience working in public relations for charitable organizations. She is the Executive Director of Internet for the Brain Injury Resource Foundation. As the parent of a son with traumatic brain injury, she has considerable experience dealing with brain injury issues. Her latest book, Back Roads Home, chronicles her family's story.