Cardiology Coding Alert

Reader Question:

Understand Facets of Medical Record Rules

Published on Thu Nov 23, 2023

Question: One of the providers in my practice likes to write their very personal impressions of patients in the patients’ notes. This makes me really nervous because the patient’s record really belongs to the patient and can be requested. I’ve tried to remind the physician of this in the past, when I’ve been reviewing notes and found some of the content surprising — and, honestly, objectionable. If a patient seen by this physician requests their records, can I provide a version that is scrubbed clean of these medically irrelevant opinions?

New York Subscriber

Answer: While patients are legally entitled to their medical records, some states, including New York, have laws saying that not all components of a patient’s health record must be turned over upon request.

According to the New York Department of Health (NYDOH), in that state, for example, a physician can legally deny access to:

Personal notes and observations,
Information disclosed to the provider with the understanding that it would be kept confidential,
Information about the treatment of a minor that the physician believes should not be disclosed, information the physician believes would cause substantial harm to the patient or others if disclosed,
Information from other providers who are actively practicing (that information should be requested directly from the respective provider); or
Substance abuse program records or other clinical records of facilities licensed or operated by the New York Office of Mental Health.

The NYDOH defines a practitioner’s personal notes and observations as their “speculations, impressions (other than a tentative or actual diagnosis) and reminders ….”

If a patient requests their records and believes the version released seems sparse, they can appeal the practitioner’s denial to “any or all of your records,” NYDOH says. The appeals process in New York means that a Medical Access Review Committee would review the records and provide a written decision. If the committee finds that parts of the record are indeed personal notes, the decision is final and cannot be pursued further, like in court.