Release

• Release of records by PCClinician, 4/7/99
  
  

"Must" you release the records to her? That's a legal question, but I suspect the answer is yes. You're right that the patient generally owns the contents of the records, and can do what she wants with them. Further, if she sues someone for malpractice she probably has to waive any right to keep the records to herself if there is the least chance they will be relevant to the suit. Patients aren't allowed to say doctor X misdiagnosed me (or something) and keep their past clinical history secret. ..... In couples, family, and group therapy, release often includes taking out the parts that identify other people. In couples therapy, one already knows who the other person is, so it's a lot harder. Since the husband has authorized release, the problem would seem to be solved (unless you have reason to believe it's a forgery). ..... I'm a little concerned about your reluctance to release the records even after her release. The law probably says you have to release the record, but it MAY allow you to send it to her lawyer instead of her if you are worried that she may be harmed by learning what you've written down. Such cases (of clinicians who don't release because the knowledge may emotionally harm the patient) must be solidly supported by the facts, and it may take a judge to determine whether or not your fears are sufficient to keep her from her own record. ..... In any case, it is NOT proper (or probably legal) to withold the record because you think it might hurt her legal case, her job, her marriage, etc. ..... Also DO NOT hold any records back, and DO NOT destroy any records once you have received the release request. You may have some embarassing margin notes or cavalier comments that you don't want others to see, but it is too late. You must release everything, INCLUDING any private or "process" notes (this is true in every case I know of, but you might check with a lawyer if you really don't want to release everything). (I once reviewed a case in which an analyst's notes were very embarassing, with margin comments similar to "only 10 more minutes and I'm rid of this BS for the weekend.")

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