Q. I requested my psychiatric records (through the record release department of my HMO) and my doctor refused to authorize the request. After 3 years of therapy (approximately 100 visits) we mutually agreed that I should see another therapist. We had been through several impasses and thought it be best to get some new insight. I requested my chart so that I could perhaps get some perspective on my treatment and how my perceptions jived with the doctors clinical assessment. He denied the request basically giving the answer that it is unheard of to read the doctor's notes. Don't I have the right to see what is in MY chart?

A. I can understand why you are surprised-and maybe angry, as well. First, though, let me just caution you that your question is fundamentally a legal one, and that I am definitely not a lawyer! That said, I can give you the psychiatrist's perspective on the release of records to the patient.

In general, the guiding principle is this: "The physical record maintained by the psychiatrist is the property of the psychiatrist. The information contained in the record, however, belongs to the patient." (RI Simon MD, Psychiatry & Law for Clinicians, 2nd ed.).

Depending on your state's laws, and perhaps judicial case law, this principle might mean that whereas your doctor MUST release certain basic information to you--your diagnosis; his treatment plan; his assessment of your progress; any pertinent laboratory data, etc.--he may not be required simply to turn over the entire record to you. Federal regulations, under the Freedom of Information Act, provide that "...agencies may deny individuals direct access to medical records, including psychological records, if the agency deems it necessary. An agency normally reviews medical records requested by an individual. If the agency determines that direct disclosure is unwise, it can arrange for disclosure to a physician selected by the individual or possibly to another person chosen by the individual."

I believe that this applies to federal facilities, but a similar principle may be applicable as per certain state laws. So, it is possible that you may be required to appoint a guardian or third party to see your records, then communicate their content to you--again, it may depend on your state's laws and state case law.

Sometimes psychiatrists genuinely believe (and with good reason) that having the patient view the raw notes from various sessions will be unduly upsetting to the patient. For example, let's suppose that in one of the first session notes, the psychiatrist had written "rule out schizophrenia". Later, he or she revises this view and rules out schizophrenia. The patient, upon seeing this initial note, becomes very upset, accusing the psychiatrist of "thinking I'm crazy!" The psychiatrist might reason, "Why should I put my patient through that, when, by the third session, I had already ruled out schizophrenia?" Still, from the patient's standpoint, this may seem patronizing and paternalistic. And yet, the psychiatrist or other physician must be committed to the patient's overall well-being and sometimes, that's a judgment call.

In any case, virtually every psychiatrist (including yours truly) thinks it's a bad idea simply to send the patient out with a folder of treatment notes. At a minimum, the psychiatrist or other mental health professional should be present while the patient goes over the notes, so that unfamiliar terms may be explained, put into context, etc.

Of course, you could consult an attorney at this point, but you may want to ask yourself how constructive that would be. Another option would be to request that your records be sent to the NEW therapist of your choosing. Then, he or she could help you decide how much of the old records should be reviewed, and whether that would really serve a therapeutic purpose.

If you do want to pursue other avenues, however, you might try contacting the National Alliance for the Mentally Ill (NAMI, 800-950-NAMI) or the Bazelon Center for Mental Health Law (202-467-5730). Good luck.and I hope you are able to move on from all this and get on with your life.

June 2003

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