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Patient, parent, and legal guardian access to medical record
Patients, parents, and legal guardians have legal right to information about a patient's care. Federal and state laws provide for the ability to obtain copies of medical records for a reasonable fee. Children's Hospitals and Clinics of Minnesota supports your legal rights and gives you access to the medical record free of charge.
If you have questions about our care, or the care of your child, please contact your/your child's physicians, nurse practitioners, and nurses. They know everything about the care being provided. They can help you understand your child's condition, the medications given, and the treatments used.
We provide interpreters to help you communicate with staff about the medical record. Please ask your nurse whenever you need an interpreter.
Ways to Access Medical Records
Nurses can show you the medical record. Children's medical record is primarily electronic but some information remains in paper. Please ask a nurse to help explain this information and what it means.
If your child is in the hospital for a long time, you can receive access to view your/your child's Electronic Medical Record (EMR) on the computer. Visit a Health Information Management (HIM) office to request this access. At Children's - St. Paul, the HIM office is located on the first floor of the Garden View Medical Building (Suite 1052) between the Red Parking Ramp and the coffee shop. At Children's - Minneapolis it is located I the lower level of the hospital immediately south of the visitor elevators (B701). You can generally receive access within one hour. Your access will automatically end after one year. Once your access is granted, you can look at the Electronic Medical Record (EMR) in these locations:
Computer in the patient room. You can look at the record using this computer when caregivers are not using it for patient care. Generally access to the medical record by families is not possible in the intensive care units (NICU/ICC/PICU) because caregivers need access constantly.
Computers in HIM Offices between 7 a.m. – 4:30 p.m. Monday – Friday.
For paper copies of medical records, visit an HIM office Monday – Friday, 8 a.m. – 4:30 p.m.
The medical record contains a lot of documents. The documents listed below are ones that would be most helpful to patients, parents, and legal guardians.
This report is created for patients who have stayed in the hospital for more than 2 days. It is completed after the patient is discharged from the hospital. The report is a summary of the reason for admission to the hospital, significant care, the diagnosis, procedures, medications, any problems, and the plan for care after discharge from the hospital. The attending physician is responsible for this report, although sometimes a resident will do the report with review by the attending physician.
History and Physical (H&P)
The History and Physical report is completed within 24 hours of every hospital admission. It gives a detailed physical examination of the patient, the history of the present illness, the family medical history, the social history, and a summary of the suspected causes of the patient's illness. Your primary or referring physician, a nurse practitioner, a resident, and the attending or admitting physician can complete the history and physical.
Operative Report (Op Report)
This report is created for every major surgical procedure for a patient. It includes the diagnosis before and after surgery as well as a detailed summary of the actual procedure. This report should be in the medical record within 24 hours of a surgery. The surgeon is responsible for this report.
Immediate Post-Op Note
This handwritten report is completed immediately after surgery. It is created by the surgeon and goes with the patient back to the room. It is a brief summary of what took place during surgery.
If the patient had something removed during an operation, the laboratory produces an evaluation of the tissue. This report often takes some time to get into the medical record because the evaluation can take several days. A physician working in the lab (pathologist) produces this report.
This form is required both at admission to the hospital and discharge from the hospital. It lists all the medications the patient takes or needs to take at home. A nurse generally completes this report.
Often, a patient will require the advice of an expert physician, called a consultant. The consultant must complete a report within 24 hours of the visit and examination. This report is a specialized history and physical examination that focuses on a particular problem or diagnosis.
This form is completed for every patient who has stayed in the hospital. It lists diagnosis; diet, activity limitations, and follow-up visit instructions. A nurse who documents the attending physician orders generally completes this report.
Copies of medical records are available from Children's Hospitals and Clinics of Minnesota Release of Information Department. We take every precaution to protect the rights and privacy of our patients. To ensure the privacy of patients and their families and to comply with federal regulations, parents or guardians must sign a Release of Information form. Processing of the request can take up to five working days.
Patient, parent, and legal guardian access to medical record
Patients, parents, and legal guardians have legal right to information about a patient's care. Federal and state laws provide for the ability to obtain copies of medical records for a reasonable fee. Children's Hospitals and Clinics of Minnesota supports your legal rights and gives you access to the medical record free of charge. Learn more.
Our Release of Information Department is open Monday through Friday from 8 a.m. to 4:30 p.m. We can be contacted by phone (612) 813-6881 or by fax (612) 813-6137.
The department releases copies of medical records only. We routinely copy the following information:
- Discharge summary
- Emergency Department Record
- History and Physical
- Operative Report
- Results of Diagnostic Tests (e.g. X-ray, MRI, laboratory, EKG)
- Immunization (shot) records
If you are requesting additional information, please specify it on the Release of Information form.
Children's Hospitals and Clinics of Minnesota will not make copies of records from other medical centers. These records must be requested from the originating facility.
Contacts at Children's for other records:
Financial (billing) records – Patient Financial Services (651) 855-2200
Immunization (shot) records – Data and Record Services (612) 813-6216
Radiology Films – (612) 813-6248
Health Information Management
General Information: 612-813-6216
For Parents and Others (Release of Information):
612-813-6881 (Minneapolis & Minnetonka)
651-220-6152 (St. Paul, Roseville & Woodwinds)
Dictation Line: 612-813-6211
Completion of Records: 651-220-6169
612-813-6898 (7am – 3:30pm, Mon-Fri)
612-813-6216 (all other hours)
Copies of Records: 612-813-6216
Electronic Medical Record
Helping you stay connected with your patients is a priority at Children's. Monitor your patient's condition and treatment via access to their Children's electronic medical record (EMR). Among the information offered by the EMR:
- Laboratory results
- Microbiology and clinical notes
Professional staff may access electronic medical records via the Professional Staff Portal.
PowerChart Outreach (PCOR)
Get the support you need and log-in for PowerChart Outreach (PCOR); the Web application that allows referring physicians (non-professional staff) real-time remote access to their patient's EMR during their care at Children's.
EMR Assistance for Professional Staff
Providers who see patients more frequently than 12 times a year at Children's must complete EMR/CPOE training. Contact the ITS Training Coordinator at 651-855-2505 to schedule training.
Access self-paced prerequisite online training
Access to real-time EMR assistance is available from another Provider, Health Unit Coordinator, Charge Nurse or Staff Nurse. These resources are available to provide assistance on the units 24/7. Monday through Friday from 6 a.m. - 8 p.m. on-site support staff are available for assistance.
If the above resources are not available, call the Children's Help Desk at ext. 3-2500. The Help Desk will contact on-call staff to assist you.
Assistance with everything from placing orders to completing documentation online is available for infrequent providers (those who see patients less than 12 times a year at Children's). If arranging for onsite support more than 24 hours in advance, you may complete the Infrequent Provider Call Ahead Assistance Form to arrange for rounding assistance. Call the Physician Access Line at 1 (866) 755-2121 or (612) 343-2121 and inform the coordinator of the date and time you will be on site to see patients or request assistance.