3.1 Complete and accurate medical records should be maintained for each patient.
Medical records are not only necessary for proper patient care but also assume important medico-legal implications. They are invaluable to the physician in defending medical liability claims. They are also of great assistance in evaluating and presenting a patient's personal injury claim. If they are sufficiently complete and legible, they may avoid the necessity, time, expense, and effort of formal reports. Because of their medico-legal importance, accuracy is crucial and such records must not be altered, supplemented, or destroyed because of pending or anticipated litigation.
Complete and accurate records should be maintained by other experts under various Colorado laws and rules, such as for attorneys and accountants. These records are also important in evaluating claims that may exist with regard to the services provided or for other issues. Such records should be available to the patient/client under similar conditions to medical records set forth in this Section 3.1 through 3.4.
3.2 A medical release authorization form, complying with all federal and state statutes and regulations, should be provided to the physician or health care provider before medical records are released.
By Colorado statute, patient medical records are available for inspection and copying upon " ... submission of a written authorization-request for records, dated and signed by the patient ... " C.R.S. §25-1-801.
Federal Privacy Acts concerning the release of drug and alcohol treatment program records also have very specific requirements concerning the contents of an authorization form (42 C.F.R. 2.31). Other federal, state, and local statutes, laws, and regulations may also limit the disclosure and dissemination of certain medically related information.
A standard approved authorization form, complying with all existing applicable laws and privacy interests, has been developed in a joint effort by the Colorado Bar Association Interprofessional Committee and the Colorado Certified Medical Record Administrators, and is included here as an Appendix. If questions arise concerning the propriety of releasing certain information, the health care provider should contact his or her attorney. The requirement by some institutions and health care providers that a special internally developed form be used is disapproved. Such special forms add undue expense and are a waste of time and effort to the institution or health care provider, as well as to the patient and attorney. The perceived advantages of internal forms are outweighed by the advantages of the standard approved authorization form.
Further, an internal requirement by a health care provider that the form be signed within a certain period of time prior to the request is disapproved, and the signed form should be deemed valid unless, by its expressed terms, it has expired.
There is no requirement that the signature be notarized. The release should identify the individual or entity to which the authorization is given, but one release may cover multiple health care providers. There should be a description of the information requested, and specific authorization should be stated if drug or alcohol treatment records or psychiatric or psychological records are requested.
3.3 A treating physician should surrender legible and complete copies of all records requested in the authorization to assist a patient in litigation and to advance the administration of justice.
Under Colorado law, a patient has a right of access to his or her patient records. An exception applies to certain psychiatric or psychological records which have special restrictions before disclosure is allowed. CRS §25-1-801 et seq.
A physician therefore has a duty to provide all information requested in a patient authorization concerning a patient's health to assist the parties and the finder of fact in the evaluation and presentation of that patient's personal injury claim. (See §1.1.)
Often times, all parties to a lawsuit will request such medical records. When this occurs, an attempt should be made to coordinate requests for medical records to avoid needless duplication of effort and unnecessary inconvenience to the health care provider.
Whenever possible, if a medical records deposition is taken and the only purpose is to obtain patient medical records, the subpoena should be addressed to the custodian of records or the physician's agent and not the physician.
Generally, the original medical records or x-rays should not be provided, but should be available for examination. While releasing original records or x-rays may pose some concerns, where necessary to release the originals, a receipt should be obtained. All copies provided should be complete and legible. If records are not legible, a literal transcription of those records may be requested.
If original records from a health care provider are required for trial purposes, this should be fully explained to the custodian of the records. Promptly following the completion of the trial, copies should be substituted in the court file for the original records and the originals should be returned to the custodian.
3.4 A reasonable charge may be requested for copies of medical records. However, the charge may not exceed that permitted by Colorado Department of Public Health and Environment regulations.
Currently, the Colorado Department of Public Health and Environment regulations governing patient access to medical records from licensed health institutions, facilities, or health care providers mandates that the maximum allowable charge can not exceed $14.00 for the first ten or fewer pages, $0.50 per page for pages 11-40, and $.33 per page for every additional page without Department approval. Actual postage or shipping costs and applicable sales tax, if any, also may be charged. The per-page fee for records copied from microfilm shall be $1.50 per page. No fees shall be charged by a health care provider of patient records for requests for medical records received from another health care provider or to an individual regulated pursuant to Section 25-1-802(1) solely for the purpose of providing continuing medical care to a patient. Chapter II 126.96.36.199. A physician or health care provider cannot charge an exorbitant fee for medical records simply because litigation is involved or he or she wishes to discourage litigation-related requests. (See § 9.3.)
If an attorney requests that a physician's hand-written chart be transcribed, an additional reasonable charge may be requested for that service.
Records should be released without regard to any outstanding unpaid balance due on the patient's bill for medical treatment. (See § 9.7.)
Although there are no current regulations for records kept by other experts, they should also be entitled to a reasonable charge for copying records. The reasonableness of the charge will be evaluated by reference to the standard set by the Colorado Department of Public Health and Environment.