Case Study: Failure to Provide Medical Records

Susan L. Marr, MSA, CPHRM, Senior Patient Safety Risk Manager, Department of Patient Safety and Risk Management.

A request for medical records is not uncommon, and understanding the requirements of a request is essential to maintain sound patient relationships and prevent legal action.

The patient, a 34-year-old female, discussed a complex dental treatment plan with her dentist but did not agree with the dentist’s recommendation. The patient wanted to consult another dentist for a second opinion before proceeding with her dentist’s treatment recommendation. She requested a complete copy of her medical records to present to the second dentist. Her dentist refused to provide the medical records, stating that the patient had not paid the full amount of her dental fees and had an outstanding balance on her account.

The patient filed a complaint with the Florida Board of Dentistry and was referred to the Florida Department of Health, where complaints against practitioners began. After receiving a letter of investigation from the Department of Health, the dentist provided the patient with her medical records, but did not include her x-rays. The Department of Health investigator suggested that the dentist consult an attorney. The attorney advised the dentist that he was required to provide the complete medical records, including copies of the x-rays, and he complied.

Risk Management Discussion

In many states, there are legal guidelines that address requirements for minimum content in dental records. Some of those requirements may include: patient history, x-rays, exam results, test results, drugs prescribed, dispensed, or administered, and consult reports or other reports relied upon by the dentist in treating the patient. Additionally, it is not appropriate for any healthcare providers to withhold release of medical records due to a patient’s unpaid or disputed fee for services rendered. Patients are entitled to their medical records with very few exceptions. It is important to know the specific laws concerning requirements for minimum content in dental records in the jurisdiction where you practice.

The following guidelines can help you avoid complaints and investigations regarding the release of complete medical records:

  • Contact your patient safety risk manager if you feel a situation is a rare exception where a request for medical records is invalid. 
  • Remember that refusing to provide medical records to a properly authorized individual who presents an appropriate request can antagonize the patient, is injurious to the patient-provider relationship and may result in a complaint to your state medical board or the Office of Civil Rights.
  • Respond promptly to requests for medical records. You are not expected to provide records on short notice, but you are required to respond in a timely manner.

Contact the Department of Patient Safety and Risk Management for guidance and assistance in addressing any patient safety or risk management concerns.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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