Do Clinical Notes Belong to the Doctor or Patient?

The body content of your post goes here. To edit this text, click on it and delete this default text and start typing your own or paste your own from a different source.You are likely familiar with the rules that when a patient requests records, you are required to provide them. The doctor is required to hold the originals, but also required to provide the patient with a copy upon request.

Clinical notes are only for the doctor, right?

Sadly no, they are considered part of the PHI and if requested must be provided.

Now, here is the pearl: “Only provide what is requested.”

In a vast majority of cases, the patient only cares about the x-rays. The next doctor only cares about the x-rays and perio chart. Don’t send what isn’t requested.

This does mean that you should monitor what goes into clinical notes. If you are offended that the patient does not like nachos, notate that somewhere else that is not required to send. Most management software programs have pop up notes or other way to keep notes on patients that are not part of the “record”.

Transferring Records

I have tried this several ways, but the easiest way to handle records transfers is through the patient directly. You want to avoid a “he said / she said” with another office that could make you look bad. If you email the patient what they want directly, you avoid potential conflict and you make it easier on the team. No need to track down the next office’s contact information.

Transfer Fees

You are legally allowed to charge the patient for records transfers. How much depends on your specific state rules, they range between $5-100. A good rule of thumb is to charge a fee to clear balances, but not to charge patients who are in good financial standing with you. Best practice is to end your relationship on a positive note if possible.

You are not allowed to hold records hostage if a patient owes you money, beyond getting them to pay for the records transfer fee.

Think Long Term

How you handle records transfers can make a difference. I cannot count the number of patients anymore that have left my office, only to return later because the grass was not greener on the other side. Once they see the differences, often they tend to become some of your better patients if you handled the transfer well.