Question

St. Joseph's Hospital has a psychiatric service in the sixth floor of the hospital. A 31 year old male has come to the HIM department and requested to see a coy of his medical record. He has told your clerk he was a patient of Dr.Schmidt, a psychiatrist, and was on the sixth floor of St. Joseph's for the last two months. These records are not psychotherapy notes. As the HIM director, the best course of action for you to take is to ____________.

1) Provide the patient with a copy of his medical record
2) Deny the patient's request for a copy of his medical record
3) Consult with Dr. Schmidt before providing the patient with a copy of his medical record
4) Refer the patient to the psychiatric service on the sixth floor of the hospital

Answer 1

Consult with Dr. Schmidt before providing the patient with a copy of his medical records to assess potential risks.

Step-by-step explanation:

As the Health Information Management (HIM) director, the best course of action is to consult with Dr. Schmidt before providing the patient with a copy of his medical record. This step is crucial to ensure that there are no psychological or other risks associated with releasing the medical record to the patient. Although patients generally have the right to access their health records, exceptions can include situations where access could harm the patient or others. Dr. Schmidt, as the psychiatric professional who treated the patient, would be in the best position to assess any potential risks associated with releasing the records. Once Dr. Schmidt has been consulted and consents, the patient can be provided with a copy of the medical record, ensuring compliance with legal and ethical guidelines regarding patient access to their health information.