Whenever a patient wants a copy of their medical records, a family member or nurse will ask for a Medical Record Request Form.
They can either fill out the form, take it down to the Medical Records Department, and get their medical information once they're discharged.
Or they can fill out the form and give it to you so you can place it directly on the front of the chart. Usually, the patient will write the address where they want the medical records sent (their doctor or themselves). By placing it directly on the front of the chart, when you break it down, the first thing that Medical Records will see is that form request, which they can get right on top of.
I take these steps once a doctor enters an order to get medical records from another facility.
Grab the Medical Records Request form. Place a patient label on the form.
Write the facility's name, the city, the state where it is located, and the telephone and fax number. If necessary I'll call the facility and verify the Medical Records Department's fax number or verify by looking on their website.
Fill in the patient's name and Date of Birth. I do not put the patient's Social Security number on the form, even though there's space for it.
The date that the patient was in that facility.
I'll write the name of the requesting doctor and what type of record they are requesting (lab results, x-ray results, discharge summary, etc).
I then hand the form to the nurse and waited for them to return it to me signed. Once it's signed, I'll get a fax cover sheet, fill in the required information and then fax it.
Once I get a fax confirmation sheet, I'll staple all 3 pieces of paper together and place it in the front of the patient's chart.
Sometimes the other facility will fax the paperwork back to the unit and sometimes they'll fax it to the Medical Records Department within the hospital.
