The term “discharge papers” generally refers to the documentation a patient receives immediately upon leaving a hospital or healthcare facility. These papers are distinct from a complete medical record, which is a much more extensive compilation of clinical data. Obtaining these documents requires navigating specific hospital departments and authorization protocols. This article provides a clear roadmap for securing both the immediate instructions and the formal medical records associated with a hospital visit.
Documents Provided at Time of Discharge
The documents handed to you before you leave the hospital room are typically a set of actionable instructions meant for immediate use, often referred to as the discharge summary or discharge instructions. This packet is a brief overview, not the full medical chart, and serves as a communication tool for your transition of care. It will contain the final diagnosis and a summary of the procedures and treatments you received during your stay.
The packet includes a medication reconciliation list detailing all current medications, new prescriptions, and discontinued drugs. The documents also outline specific instructions for post-discharge care, such as dietary restrictions, wound care protocols, and limitations on physical activity. You will also find information regarding scheduled follow-up appointments and guidance on symptoms that would necessitate a return to the emergency department. Review these instructions with the discharging nurse or case manager before leaving to ensure all details are clear and understood.
Requesting Complete Medical Records
Obtaining the full, formal medical record requires a structured request process separate from the immediate discharge instructions. The complete record includes physician notes, laboratory results, imaging reports, operative reports, and the comprehensive discharge summary. You must direct your formal request to the hospital’s Health Information Management (HIM) department, which is also commonly known as the Medical Records Department.
To initiate the process, you must complete a formal document, typically titled an Authorization for Release of Information form. This standardized form is mandatory and allows the hospital to legally share your protected health information. Hospitals usually make this form available on their website, through an online patient portal, or directly at the HIM office.
When filling out the form, you must accurately specify the dates of service and clearly describe the exact documents you wish to receive. Submitting the form can usually be done via mail, fax, or a secure electronic portal, depending on the facility’s capabilities. Once the request is received, the hospital has up to 30 days to respond under federal regulation, though many facilities process requests faster.
Authorization Requirements and Associated Costs
The process of releasing medical records is strictly governed by federal and state privacy laws, which mandate who can authorize the disclosure of protected health information. Generally, only the patient, or a legally designated personal representative, can request and receive a copy of the medical record. A personal representative includes a parent of a minor, a legal guardian, or an individual with a valid healthcare power of attorney.
If you are requesting records on behalf of a deceased patient, you must provide documentation establishing your authority, such as a death certificate or proof of being the executor of the estate. All requests for records, even from family members, require a valid, signed Authorization for Release of Information form to ensure compliance with privacy regulations.
While patients have a right to access their medical records, hospitals are permitted to charge a reasonable, cost-based fee for fulfilling the request. These fees are generally intended to cover the labor, supplies, and postage involved in copying and preparing the records. The fee structure often varies depending on the format requested, with a maximum flat fee sometimes applied for electronic records, such as those provided on a CD or via a secure download.
Fees for paper copies are often calculated on a per-page basis, typically with a higher rate for the first few pages. If the records are being sent directly to another healthcare provider for continuity of care, the copying fees are often waived entirely. Knowing the required documentation and the potential cost structure in advance can help streamline the process.