Your Right to Conduct an On-Site Inspection of the Electronic Medical Records

Pursuant to federal regulation, patients or their legal representative, have a right to inspect their medical record. 45 C.F.R. section 164.524 grants the patient, and their legal representative, the right of access to inspect and obtain a copy of protected health information about the patient. Protected health information includes information transmitted by or maintained by electronic media. 45 C.F.R. section 160.103 (2023).

The HITECH Act of 2009 clarifies that 45 C.F.R. section 164.524 applies to electronic information and when you ask to access protected health information, you have the right to get it in electronic format.

Additionally, section 18 of New York’s Public Health law allows a patient to make a written request to a hospital to copy and inspect all or part of their health care information and requires the hospital to promptly respond within 10 days.

The inspection of the records will show alerts, popups and best practice advisories and segues into other modules with their own audit trails, e.g., radiology records may have their own audit trail separate from the other parts of the EMR.