The Medical Record

WHAT IS A MEDICAL RECORD?
Every patient (student or employee) who receives health care services at the McKinley Health Center has a medical record; this is consistent with the national standard of medical practice. The medical record is a systematic documentation of a patient's medical history and care. Entries in the medical record are made by physicians, nurses and other members of the health care team.

WHAT INFORMATION IS IN THE RECORD?
Information in the record includes:

• your identification information (e.g., I.D. number, local and permanent address, etc.);

• your health history (what you tell the health care providers about your past and present health status);

• your medical examination findings (what the health care providers observe when you are examined).

Other information may include lab test results, medications prescribed, referrals ordered to health care providers outside McKinley, educational materials provided, and what plans there are for further care, including patient instruction for self-care and return visits.

WHY IS THIS INFORMATION KEPT?
The information in the medical record is necessary to provide continuity of care. This means that all the appropriate health care providers who treat you have access to your health history.

The medical record also serves as a basis for planning patient care; to document communication between your health care provider and any other health professional contributing to your care; to assist in protecting the legal interest of yourself, McKinley Health Center and the health care provider responsible for your care; and to document the care and services provided to you.

WHO HAS ACCESS TO MY MEDICAL RECORD?

Medical record
Only authorized McKinley Health Center staff members have access to your medical record. Your written consent is necessary before any information from your medical record is shared with any organization, law enforcement official, prospective employer, insurance company or other individual(s). In some instances, the courts can subpoena the medical record as evidence in a trial without the patient's permission. Access by a parent differs depending upon your age. If you are eighteen (18) or older, parents have no access to your medical record without your permission. In most cases, if you are seventeen (17) or younger, your parents can have access to your medical information with the exception of information concerning sexuality issues (e.g., pregnancy, contraceptive services, sexually transmitted infection treatment, sexual assault) and alcohol/drug or mental health treatment.

Mental health information
For students 12 or older, mental health information is completely confidential, and can be released only with the specific state required release form signed by the student. The only exceptions to this rule are when there is an immediate danger to life or instances where the student brings up their mental health during litigation. If you have specific questions about access or release of information from the record, it is recommended that you contact directly McKinley's Mental Health Department, 333-2705, for accurate and complete information.

MAY I SEE MY MEDICAL RECORD?
Any patient wishing to review his or her medical record should call 265-0798 to schedule an appointment. Upon signing a release of information authorization form and presenting your University of Illinois identification card, you will be able to review your medical record in the presence of the Medical Record Administrator or designee.

If you have questions regarding the contents of your medical record, which cannot be answered by the Medical Record Administrator, you will be referred to the McKinley Health Center staff member most appropriate to address your question.

HOW DO I REQUEST A COPY OF MY MEDICAL RECORD?
You may request a copy of your medical record for yourself or another health care provider by coming to the Medical Records Unit. You will need to show your University of Illinois identification card and sign a release of information authorization form. You will also be given information at that time about any costs for this service. If you are requesting a copy of your record to be sent to another health care provider or facility, there will be no charge for copying. (For more specific information on copying costs, you may call the Medical Records Unit at 333-2720, in advance of your visit.)

ARE SOME CONDITIONS REPORTED TO THE HEALTH DEPARTMENT, THE POLICE DEPARTMENT OR THE UNIVERSITY LEGAL COUNSEL WITHOUT MY PERMISSION?
Illinois statutes govern the reporting of certain conditions to the Public Health Department without the written permission of the patient. McKinley Health Center is required to release such information to the Health Department only and to no one else unless requested by the patient. The Police Department must be notified in cases of sexual assault and other criminal offenses including injuries from firearms. Also, records may be released to the University Legal Counsel if litigation is threatened.

WHAT HAPPENS IF A PROSPECTIVE EMPLOYER OR INSURANCE COMPANY ASKS FOR A COPY OF MY MEDICAL RECORD?
Records are not sent without an authorization to release information signed by you. Most insurance companies have their own authorization form for you to sign. These generally are a "blanket" release authorizing release of all medical, mental health and documented HIV information from your record. If the authorization is valid (i.e. meets Illinois statutes for release of mental health and HIV information) all of your records will be released. If you do not agree with the authorization for release of information you are asked to sign, you should discuss this with the company before you sign the release.

IS INFORMATION FROM MY VISITS TO THE MENTAL HEALTH DEPARTMENT INCLUDED IN MY MEDICAL RECORD? WHAT ABOUT CONFIDENTIALITY?
The mental health information is kept in a separate section of the general medical record. This information in the mental health section is subject to additional regulations beyond those required of general health records, to further protect its confidentiality. A separate release form must be signed by the student if mental health information is to be released. There is an exception if there is an immediate danger to life - and then, only pertinent information is released, and only as long as the crisis persists.

SUMMARY
The medical record is an important component of your health care. McKinley Health Center encourages its patients to participate actively in all aspects of their care, including access to their medical record. If you have questions or concerns about your medical record or in the information above, you are encouraged to contact the McKinley Health Center, Medical Records Unit at 333-2720.

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