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One of the most important factors in providing quality care is for a health care provider to have all information pertinent to a patient’s health. For instance, knowing that a patient has a history of seizures may influence the type of attention medication that a doctor would prescribe. Similarly, knowing that a patient has a history of learning disabilities will affect the interpretation of neuropsychological and speech pathology testing. On the surface, it would seem pretty obvious that a health care provider would need all available information on a patient under his or her care. In reality though, providers all too often have access to surprisingly limited information which makes assessment and treatment more difficult than it needs to be.
Many patients and their families simply assume that each health care provider they see knows what every other provider in the chain of care is doing or has done. Unless the health care providers in question all work for the same facility, the providers do not have this full and free access to one another’s information. Patients (or loved ones that have the legal right to do so) must request that the information from one health care provider be sent to any other health care provider. This will always be done with a written form called a Release of Information or Release of Records. This release allows the providers specified on the form to share information. So if you want your family care physician to have a sufficiently comprehensive understanding of what happened to you in the hospital, you want to make sure that you have signed a release of information authorizing the hospital to send information to that physician.
There will often be check boxes on these forms specifying what information is being sent. Certain information such as psychological records have added legal protections so they cannot simply get sent automatically with other records (consider, do you really want your insurance company to have the same access to session notes from marital therapy sessions as they do to those from physical therapy sessions?). Moreover, doctors/facilities will only send the records from their own offices, and not the records from other offices. For example, if you are requesting that notes from a rehabilitation facility be sent to your family doctor, the rehabilitation facility will only send their records to that doctor. They will not send the notes from the hospital you were at prior to the rehabilitation facility even if the facility has those hospital records. Each doctor/facility will require a release of information to be signed and often they will insist that it be on a release form from their office. Though this may seem like a bit of an inconvenience, having a full set of records greatly improves the ability of health care providers to give the best possible treatment to their patients and reduces the likelihood of wasted time and costly errors.
Learn about how Moody Neuro can help with neuropsychology and counseling, speech and language disorders, physical therapy, outpatient rehabilitation assistance, community integration programs, and occupational therapy.
Moody Neurorehabilitation Institute (Moody Neuro) provides personalized care to treat the unique challenges of brain injury with the singular purpose of achieving the best possible outcome for patients and their families.