May I read your medical record?

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May I read your medical record?

By Domanique F. Culpepper, MPA, RHIA, CPhT

Every visit you make to a doctor’s office is recorded in standardized medical codes. Your surgeries, emergency room visits, and even medication refills, they are all translated into standardized medical codes. These codes tell a medical story about your life. Have you ever stopped to think whether you care about who reads your medical record?

We are able to determine the diseases that affect certain races and age groups. For example, codes within the 250 series, which pertain to Diabetes Mellitus, are commonly documented within the medical records of Blacks... 414 series, which pertains to heart disease. Other health conditions and diseases, such as pregnancies, Sexually Transmitted Diseases (STDs), and accidents, for example, are all similarly documented.

The medical record is also a legal document, and can be used in court for various reasons. A few examples of court cases that may require subpoena of a medical record could be domestic violence, rape, or mental capacity determination. I used to professionally review medical records to determine whether claimants met the criteria for specific disabilities, according to Social Security Administration (SSA) guidelines.