Medical Records
Adopted: Sun, 2010-09-26
Back to Position Statements
Reviewed 2014-11-13 - no changes
A podiatrist's policies and practices relating to medical records under their control should be designed to benefit the health and welfare of patients, whether current or past, and should facilitate the transfer of clear and reliable information about a patient's care. Such policies and practices should conform to applicable federal and state laws governing health information.
It is the position of the North Carolina Board of Podiatry Examiners that notes made by a podiatrist in the course of diagnosing and treating patients are primarily for the podiatrist's use and to promote continuity of care. Patients, however, have a substantial right of access to their medical records and a qualified right to amend their records pursuant to the HIPAA privacy regulations.
Medical records are confidential documents and should only be released when permitted by law or with proper written authorization of the patient. Podiatrists are responsible for safeguarding and protecting the medical record and for providing adequate security measures.
Each podiatrist has a duty on the request of a patient or the patient's representative to release a copy of the record in a timely manner to the patient or the patient's representative, unless the podiatrist believes that such release would endanger the patient's life or cause harm to another person. This includes medical records received from other podiatrist offices or health care facilities. A summary may be provided in lieu of providing access to or copies of medical records only if the patient agrees in advance to such a summary and to any fees imposed for its production.
Podiatrists may charge a reasonable fee for the preparation and/or the photocopying of medical and other records. To assist in avoiding misunderstandings, and for a reasonable fee, the podiatrist should be willing to review the medical records with the patient at the patient's request. Medical records should not be withheld because an account is overdue or a bill is owed (including charges for copies or summaries of medical records).
Should it be the podiatrist's policy to complete insurance or other forms for established patients, it is the position of the Board that the podiatrist should complete those forms in a timely manner. If a form is simple, the podiatrist should perform this task for no fee. If a form is complex, the podiatrist may charge a reasonable fee.
To prevent misunderstandings, the podiatrist's policies about providing copies or summaries of medical records and about completing forms should be made available in writing to patients when the podiatrist-patient relationship begins.
Podiatrists should not relinquish control over their patients' medical records to third parties unless there is an enforceable agreement that includes adequate provisions to protect patient confidentiality and to ensure access to those records.*
When responding to subpoenas for medical records, unless there is a court or administrative order, podiatrists should follow the applicable federal and state regulations.
[*] See also Position Statement on Departures from or Termination of Podiatry Practices