Practice Management System and Portal for Mental Health Professionals and their Clients

PSYBooks Reports

/PSYBooks Reports

When You Have to Produce a Medical Record

Before I started using practice management systems, being required to produce a client’s medical record was a bit scary for two reasons:

  1. First, I typically only received those requests when something important was going on, i.e., a legal proceeding of some sort, a disability or worker’s comp situation, or maybe something having to do with insurance. They were the kinds of things where I felt that a lot might be at stake for my client (and/or for me) so I wanted to make sure I “did it right”.
  2. Second, although I had my own system for organizing client files, the reality is that my records were scattered everywhere. I kept files on current clients in one filing cabinet – unless a certain file got too big, in which case I moved older portions of it to another filing cabinet, unless there was also large artwork in the file, in which case it had to go in the lateral filing cabinet. When a client terminated, files got moved to a storage area in my basement at home. If the client later returned and their file had been especially large, part of it would be brought back to my office, but older parts remained in my basement at home. Then, of course, some documents were on my computer – a smattering of various Word docs and Excel sheets I had pieced together for special notes I had written on clients, letters I had written on their behalf, and various attempts at coming up with THE perfect method for determining how much a client owed me when insurance was involved. I had also tried efiling for awhile at various insurance company’s websites, so some of my records were on various sites on the Internet, too. Somehow, when I was asked to produce a medical record, even though I knew I had everything I needed, finding it all and pulling it all together into some type of meaningful report was a daunting task.

By |2019-04-10T12:39:37-04:00June 15th, 2014|HIPAA/HITECH, PSYBooks Reports|Comments Off on When You Have to Produce a Medical Record