Requests for all information (progress notes, consent forms, registration sheets, etc.) can delay processing and become very costly. If you need help deciding what to request, a patient information coordinator will assist you. Call 513-636-8233.
If you are requesting information for continuing patient care, the caregiver receiving the information usually wants only an overview of the important information. (This usually meets the need for individual use as well.)
A patient / physician abstract contains:
- Discharge summary − The care, treatment and services provided as well as progress toward established goals of an inpatient stay
- Emergency record − The care, treatment and services provided for a visit to the emergency room
- History and physical − The present illness or care needs and notes about any important history
- Operative report(s) − The surgeon’s findings, technical procedures used, specimens removed and post-operative diagnosis
- Consultation report − The findings of a physician requested to examine a patient
- X-ray reports, labs or other tests
- Clinic notes − Include the initial assessment and the most recent visit documentation
If you are an attorney and submit a subpoena for medical records and you are not the prosecuting attorney requesting records for reasons of child abuse or neglect, please also submit the Authorization for Use and/or Disclosure form signed by the patient/parent/legal guardian or a Court Order signed by a Judge or Magistrate. This will help ensure a timely response and valid record retrieval process.