In Massachusetts and most other states, you have the right to get copies of your medical and hospital records. In theory, the process is simple: just make a written request to your doctor, hospital, or other health care provider. Include your name, address, date of birth, and a description of the records you want to receive. A hospital is required to respond to your request within thirty days if the records are kept in the hospital, or sixty days if they are stored in an off-site location. Many hospital websites provide specific information and authorization forms for use in requesting records from the facility. It’s usually a good idea to call the provider before submitting your request to make sure you’re sending the right form to the right address.
If you are the parent of a minor child, you may request your child’s records. If you are the administrator or executor of the estate of a deceased person, you may request records for the decedent. Sometimes the provider will release the records of a deceased person to the surviving husband or wife, or to the person named in the will as executor, but many institutions require a formal probate court appointment.
In Massachusetts, the provider is permitted to charge you a reasonable fee, set by a statute, General Laws, Chapter 111, Section 70, for retrieving and copying the records, unless the records are for use in a Social Security claim, or for a federal or state needs-based program. The provider may not withhold the records because you have not paid a bill for medical services. A hospital is required to keep records for 20 years from the date the patient is last seen. A doctor must keep records for seven years, or until the patient reaches age 18.
When requesting records, it is important to be specific about which records you are requesting. Particularly where the records are voluminous, or cover a long period of time, a hospital may provide only a summary or abstract of the records. Depending on the purpose of the request, this may or may not be sufficient. You are also entitled to receive copies of x-rays, CT or MRI scans, and other imaging studies. Many labs and hospitals will not release pathology slides directly to the patient or an attorney, but will send them to another health care provider.
Georgetown University has a website that attempts to track requirements and time limits for requesting medical records in each state. This site includes specific information for Massachusetts, New Hampshire and Rhode Island. The Massachusetts Board of Registration in Medicine also publishes a brochure to help patients understand their rights in this area.
If you’re considering a medical malpractice claim, you may want to consult a lawyer before requesting your medical records. A lawyer will be able to help you determine which records are necessary to evaluate a potential case, and most lawyers will handle the requests for you. Health care providers tend to interpret medical record requests quite narrowly, and will normally respond only with copies of records they created, omitting information received from other providers, administrative and billing documents and similar material. If the purpose of a request is to investigate a medical malpractice case, there may be other important documents in the provider’s file that must be specifically requested. These may include correspondence, records from other health care providers, billing records, history or information forms completed by the patient, and phone messages.
Most patients–and even many lawyers–do not realize that there may be important information that a hospital will not include even in response to a request for the complete record. An often overlooked category of records includes certain anesthesia and surgical monitoring documentation. For some reason, many hospitals do not consider these documents to be part of the patient’s record, and will not include them even in response to a request for the complete hospital record. In a case involving surgical or anesthesia negligence, this documentation may be critical, as it contains detailed information not found in any other record.