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What Should Be Included In Medical File

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Mec4040

Member
What is the name of your state? NY

I had a new question that relates to my previous, and was not sure if I just added it to the first one, if it would have been read.

I received today the records from the doctor, but still feel there is material missing. I'm not asking if other doctors notes should be in there, because we discussed this already. I'm talking about material just from this doctor.

All I received was the office visit report for each month I was seen. Should there be other things like reports from labs, and should the doctor have included the informed consent?

Its been about 4 years since the first visit, and dont remember signing an informed consent. And would like to know if this should have been included.


Thanks again,

PS: Again, I apologize if this should have been posted in first topic. But felt because it was a new question, if I asked in old topic it would not be read.
 


ellencee

Senior Member
What is the name of your state? NY

I had a new question that relates to my previous, and was not sure if I just added it to the first one, if it would have been read.

I received today the records from the doctor, but still feel there is material missing. I'm not asking if other doctors notes should be in there, because we discussed this already. I'm talking about material just from this doctor.

All I received was the office visit report for each month I was seen. Should there be other things like reports from labs, and should the doctor have included the informed consent?

Its been about 4 years since the first visit, and dont remember signing an informed consent. And would like to know if this should have been included.


Thanks again,

PS: Again, I apologize if this should have been posted in first topic. But felt because it was a new question, if I asked in old topic it would not be read.
If the lab work values are not reflected in the notes, then ask for copies of the labs. Consent for treatment is in a separate part of the records and is not included in usual records for copies of records. You've seen this MD for 4 years, consent is not an issue.

EC
 

Betty

Senior Member
Did the doctor's office charge you for copies of the records sent - many do. (& they have the right to) Request what you are missing & let the doctor's office know you are willing to pay to get complete records - lab work, etc.
 

Mec4040

Member
Hello,

First, I want to thank you all for stopping by. Ellence, the reason I mention about the consent form, was because I dont think it was ever signed. You mentioned after 4 years one is not needed, and I understand that...however at the very first appointment, this physician should have had me sign one...and I dont remember if I did and that is what I would like to find out.

Ecmst12...I explained that I was sorry and the reason why I posted this was mainly because it's a new question. My first thread...asked if the doctor MUST provide ALL letters from other doctors that are in my folder. The second thread...asked what type of files should have been copied when I requested them. Aside from it being a different question, I was concerned that if I asked the new question in the same thread, it might not be answered because the people who read and or answered it already, would miss the different question. I did not mean to cause any problems.

Betty...the doctor did not charge anything...and I asked 4 doctors all of which didnt charge...so guess I was lucky in that sense. As for contacting the doctor and telling him what is missing...this is what I plan to do, and that is why I wanted to know what I can and cannot request.

I know the whole thing that comes with (assuming) and its my fault...for thinking when I wrote and signed the letter, asking for my complete medical record and to please copy everything. I didnt think I would need to name each.


Thanks again everyone for taking out the time and trying to help,
;)
 

Betty

Senior Member
If you're missing lab test results, call & ask for them & let doctor's office know you are willing to pay for the copies & see what they say.
 

Mec4040

Member
Hello,

I plan on calling the office and asking for the lab reports. That was not the problem. I wanted to know aside from the lab reports what are some other reports that I have the right to have copied.

Thanks
 

lealea1005

Senior Member
Hello,

I plan on calling the office and asking for the lab reports. That was not the problem. I wanted to know aside from the lab reports what are some other reports that I have the right to have copied.

Thanks


If you asked for your complete medical record, everything included in your chart should be provided to you. This may include laboratory/diagnostic testing reports, immunization record, prescription/medication list, as well as office notes The only exception would be Psychiatric notes which are released at the discretion of the Physician.

What, exactly, do you think is missing from your record? You must be looking for something in particular.
 
Last edited:

Mec4040

Member
Hello,

lealea1005...what you wrote is exactly the kind of thing I needed to know....thank you sooo much!!!

You mentioned that I might be looking for something particular...and that is not the case. It was a matter of wanting to know what should have been in the folder.

The problem is when I receive my copies, the only thing there was the chart for each office visit...and that's it...nothing else was there.

I know there is more in the folder. What else can I say or do to get the rest of my records? Please if anyone knows, post it here its very important.


Thanks
 

ellencee

Senior Member
I know there is more in the folder. What else can I say or do to get the rest of my records? Please if anyone knows, post it here its very important.
Thanks

Your question has been answered over and over and over. Is your motive for repeatedly posting the same question something other than wanting an answer about requesting and receiving medical records.

EC
 

lealea1005

Senior Member
Hello,

lealea1005...what you wrote is exactly the kind of thing I needed to know....thank you sooo much!!!

You mentioned that I might be looking for something particular...and that is not the case. It was a matter of wanting to know what should have been in the folder.

The problem is when I receive my copies, the only thing there was the chart for each office visit...and that's it...nothing else was there.

I know there is more in the folder. What else can I say or do to get the rest of my records? Please if anyone knows, post it here its very important.


Thanks


You can make a request to view your medical file at the office. They should set up an appointment with you to view it and, at that time, you can ask that they copy any missing records. Be prepared to pay for the additional copies.
 

lealea1005

Senior Member
Your question has been answered over and over and over. Is your motive for repeatedly posting the same question something other than wanting an answer about requesting and receiving medical records.

EC

You're not kidding...and on more than one website!
 

Mec4040

Member
Hello,

ellencee...what is the big deal? Am I being rude or nasty to anyone? If anything, I have to question your motive for wasting your own time...why do you care.

To answer your question...I asked the same question on another board, is this some kind of internet crime? As for my post being answered...Umm...sorry but no it has not really been answered and that is why I have asked nicely..for extra advice.

One person, whom I mentioned before, listed a few things that should have been in the folder and I thanked them. If you look back, you will noticed the post might have answers however, they don't answer my question...so where is the harm in me asking if anyone else knows to please come by and post it?

Thanks
 

ellencee

Senior Member
:rolleyes: Thanks for the rant.

If two sites haven't answered your questions, yet, consult with an attorney of your choice.

EC
 

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