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When taking office visit notes, I typically include medical information on the same page as information relating to depression, alcohol treatment, and so forth. Before releasing a record, should I obscure all psychiatric and alcohol-related references?
Q: When taking office visit notes, I typically include medical information on the same page as information relating to depression, alcohol treatment, and so forth. Before releasing a record, should I obscure all psychiatric and alcohol-related references?
A: No, provided the patient has agreed to a release of the full record. Under HIPAA, an authorization for release of medical information must specify what, in fact, the patient is agreeing to have released. For this reason, and in order to protect yourself from any potential problems, ask patients who authorize release of their medical records if they want their entire record released, including both psychosocial and medical information, or just a partial record. If the latter, release only that part of the record that the patient has authorized.