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Medical Records

sleeprgirlssleeprgirl Posts: 695
edited 06/11/2012 - 8:48 AM in Chronic Pain
Many of you know that I went to see an interventional pm doctor back in August, and had three endoscopic lysis of adhesions that surrounded my fusion. This doctor required that I see the Pain Psychologist in his office, which I did three times.

These procedures were excruciatingly painful for me, and I was unable to have any contact with the pm doctor to address and treat the symptoms that I was and continue to have. I had to call my neurosurgeon for help, and he and his PA have been treating my pain for now. My NS and I agree that I need to find another pm doctor, which I am looking for right now.

I always get copies of all my medical records, imaging, PT records, etc. However, I had never received records from the Pain Psychologist.

Today, I called to get those documents for my personal records. I was told that they could not give me those records, but could only give a certain portion of the records to another doctor or to a lawyer.

Does anyone have experience with this issue???




  • I had that problem once with a different doctor...That was until I reminded them that I have a right to have access to my records and if they didn't allow me to have a copy of the records I'd be happy to have my lawyer contact them and then the office personal were more then happy to provide me with a copy for a $5.00 fee. Of course I no longer see that particular doctor and the doctor I took the records to mentioned the records weren't worth the paper they were one, except for the test results. Since then I make sure to always get a copy of my record and/or test results before leaving the office. Many offices do charge a fee for the records, but I have found if I ask on the day I am there, they don't charge.

    Below is what HIPPA states:

    "The HIPAA medical privacy law gives you the right to see and get copies of your own medical records. There are a few exceptions. For example, HIPAA does not give you the right to access psychotherapy notes or information compiled for use in litigation. Your request may also be denied if the provider decides access to the records could result in harm to you or another person.

    In addition to HIPAA, many states have laws that allow patients or their designated representatives access medical records. State laws may give you more, but not less, privacy than HIPAA."

    Hope this helps.
  • He can charge you a copying fee, but he can't deny you access to them. He cannot charge a fee to send them to another doctor.
  • OH My! Just what you & I were talking about before. My daughter had something like this happen and her hubby went into the pain clinic office with the HIPPA law in hand. They STILL refused to give him or her the records which were needed for a soon upcoming Dr appt. FINALLY her GP asked for them for her and he got them and gave them to my daughter. what BS!!!!! :(
    L1 - S2 "gone" useless in 1 way or another. DDD. RA. Bone Spurs. Tons of nerve damage/issues. Stenosis. Both knees replaced. 50 yrs old. I had a great fall (hence my user name) at age 41 and it has been a domino effect every since.
  • said something about there being laws about psychiatric records, and they could not give them to patients. He is a PhD psychologist, so I do not understand the issue. I want to get my facts straight first. Maybe there is something about them that i don't know about.

    I will say that I have never in 50 years had an experience with a physician like this office. Nor in my anesthesia practice either.


  • You're having trouble getting your records, but coming out of your old PM's office, I am not surprised!

    I can tell you I asked and received copies of my chronic pain psychology testing results.

    Perhaps you can ask your PCP or the PA at NS office to request them (sign a release). I don't understand the mentality nor the logic of the pm's office, I am just glad you are done with then.

    Take care,
  • Lisa,

    YOU as the patient has the right to FULL access of your records via HIPPA! Some doctors offices try to play games in that the doctor has to sign off on them, not true. You have a RIGHT to those records as they regard YOU as the patient. Some do require you to appear at the office to get them, and too they can charge for the "copies"...but it is YOUR right. I hope this gets worked out woman. :)

    PCTF C4 - T2, Laminectomies C5, C6 & C7. Severe Palsy left arm/hand.
  • I just read that psychotherapy notes are treated differently under HIPPA. I have downloaded the Summary for Privacy Rules by the Office of Civil Rights. It is very long, so I am going to read it in the am.

    Virginia, thanks for letting me know that they can be given to the patient.

    Brenda, thank you as well. There are rare reasons evidently that prevent you from getting records, like in cases of substance abuse. But that is not the case here. I was asked by the pm doc to see this pain psych. before my first visit. It seems a standard practice for this office. I was willing to see him, because I am open to all modalities of therapy for pain control.

    I will let you know what I find out tomorrow.

    Thanks all,

    nite, nite,

  • There are cases where we do not have the right,even under HIPAA to our own records.
    These are generally Psychiatric or Psychological in nature,and the reason is because the patient could be harmed by something they read about themselves,as written by another party-in this case their Psychologist or Psychiatrist, and these Drs are protected from disclosing your records to you,but can be released with a court order.IF the Dr doesn't want to release them that is.

    Even when we get our regular medical records,a lot of Drs notes are taken out of the reports and kept away from the patients eyes..for emotional and Psychological reasons.
  • I just saw your note...I appreciate it!

  • I found this encounter record written by my Surgen, this was 6 months post. op. #2 back in 2014
    The point I would like to share is,: that on this date the Surgen stated that he could not justify an extension of my State Disability Insurance. Saiid MRI looks good I'm sorry .

    I have not been able to get him to come in for a visit because of pain and financial/travel constraints. He is currently on disability and unemployed. Lives in a trailer and depends on others for basic needs. He can dress, bath, and perform some ADLs at this time.
    I ordered an MRI of his whole spine to find a cause. I reviewed the imaging, which shows no recurrence or new tumors, complete resolution of his cervical cord signal change, excellent decompression of the lumbar stenotic area and fusion of the L2-3 vertebrae. The xrays do not show any issues with his instrumentation. The soft tissues are well healed, without evidence of dehiscence or infection.

    On exam, his incisions are all well healed. His paraspinal muscles are stiff. Limited ROM in the neck and spine. Frequently curses under his breath. Full strength (mild pain limitation) throughout with normal reflexes. Tone normal.

    I am not certain of the origin of his back spasms. At this point, we have ruled out instability, pseudarthrosis, tumor recurrence, infection, and dehiscence.
    We can move forward and treat his spasms with acupuncture, massage, stretching, physical therapy, aquatherapy, botox injections, medications.

    He was very tearful due to pain during his visit. Though I cannot find an organic cause of his pain, he is certainly in no shape to hold any job at this time.

    I spent 15 minutes with this patient; greater than 50% of the time involved counseling the patient and discussing neurosurgical care, coordinating a plan of care, obtaining a history, reviewing all relevant neuroimaging, performing an examination, and answering all questions to the best of my ability.

    After review of my note for this encounter, I recall this visit and am addending this note to state that this patient has a more specific diagnosis of: hx of benign spinal cord neoplasm. Surveillance scans are required given then possibility of recurrence

  • SavageSavage United StatesPosts: 5,476
    edited 01/11/2016 - 9:58 PM
    If I'm reading your post correctly....Doctor seems to be contradicting himself...re your ability to work....and then not being able to hold down a job.
    What amount of extra searching and discovery for you to have undertaken!....while in your pain.

    I sure hope all went through for your continued Disability insurance.
    Spine-Health Moderator
    Please read my medical history at: Medical History

  • It would not look good on his record for his patient to remain disabled after being the first in his organization to attempt the Surgery?
  • PlumbTuckeredOutPlumbTuckeredOut Philadelphia, PAPosts: 325
    edited 01/12/2016 - 5:26 PM
    Again, this varies from state to state. I worked in psych in Rhode Island, Massachusetts, and Maine. We write out notes typically in three sections; Data- the facts and only the facts. Those things which are directly observable, looks, sounds, feels (to the touch not emotion), smell. Second part is Assessment- this is my opinion on what I can observe. It takes in matters of comparing this visit to the last. It includes me "gut reaction" and instinct. The last part is Plan- what I suggest needs to be done. It can be "Continue current treatment" or refer to " ".

    To be reimbursed my insurance I needed to complete my notes as above. For a patient requesting medical notes, they only had to be given the data and the plan- my assessment would not be included. Assessments are invaluable between providers but not always so much for the patient. (Sometimes the truth can hurt!)

    In medical, from talking with friends, I know that "discussion" between providers, although possibly included within "your" medical records, is not yours to review. There was a neighbor I used to care for in another state. I would take her to her medical appointments and she was a cantankerous old lady. She would be very belligerent about wanting things done her way but she was a heavy smoker and ate about 4 pounds of bacon a week as a start! She badly wanted surgery for her back pain and for her rotator cuff pain. Finally one of her providers just showed me that with my neighbors physical health stats she would die under anesthesia. Then they gave me that god- awful job of trying to communicate to her that her overall physical health would kill her long before pain would. Other things she said, when she would "joke" about suing for lack of care- all these sorts of things were noted and considered serious.

    We assume that medical records are just about our failing backs and arthritic toes but they can include all kinds of facts, statements, opinions, insurance statements- anything and everything. There is a good reason why "Ignorance is Bliss" is still a well known saying.


    Two roads diverged in a wood, and I took the one less traveled by...... (Robert Frost)
    I still don't know if I should have taken the one that said, "Caution! Dead End" (Me)
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