Everyone involved in health care knows that having historical information on a patient is important, especially when the patient is relatively new to the provider. The most meager of prior records still help to fill in the medical picture and offer background on what is – and isn’t – wrong with the individual. In addition, old medical records are extremely important for the MRA chart reviewer, who often mines those records to identify incidental information that may result in risk adjusted conditions.
At the risk of being elemental, let’s go over the importance of past records. First, every practice has – or should have – a process for requesting, and following up on, prior info. This process begins at, or slightly before, the first visit and a valid medical records request should be directed to every provider the patient has seen in the last few years. Not an easy task. The main reason to blanket the provider landscape with requests is that a prior PCP may not release everything in the chart. Since the provider – and not the patient – is the owner of the record, he or she can determine what will be released regardless of any stipulation of “all records” on the release form.
Some providers release only the documents they created in their practice, namely visit notes and perhaps laboratory reports. Others release visit notes and all imaging and lab info. On the other side of the continuum is the practice that releases the whole record, fax cover sheets, hospital documents, everything. We love those guys!
The receipt of records can take several requests and you definitely need a practice-wide policy for the process and its timeframes. How often do you follow up? How do you follow up on outstanding requests? How many times do you fax a request before making a phone call (and maybe, a friend)? If requests are taking a long time, or records are not forthcoming, you might re-revaluate what you’re asking for: do you really need the whole record? If you’re requesting records from a specialist, the last visit note is usually sufficient. Try asking for that, which may be easier for them to send quickly and just as useful for your purposes. if it’s an old PCP, maybe try limiting your request to the last two years.
Last thing is to make sure you update your records so you don’t re-request the same thing over and over again. And while we’ve got our chart reviewer wish list out, how about filing the same document only one time as opposed to the three or four times we’ve found in many charts, AND titling the document with the specialty name and date of service.