Medical Records and the Law

304 CHAPTER 8: DOCUMENTATION AND DISCLOSURE:SPECIAL AREAS OF CONCERNexample, a New York statute provides that certification from a statelicensedphysician must cite a serious physical or mental illness toshow “good cause” and identify the information required to addresssuch illness. 127Responding to Records RequestsHealthcare records personnel usually do not encounter requests fromindividuals seeking to inspect a medical record where the request is eitherprimarily or incidentally premised on a desire to obtain informationabout the adoptee’s biological parents. Parties to an adoptionmore often address such requests to either the agency that handled theadoption or the court that entered the adoption order. Requests arealso directed to the healthcare institution, however, and healthcarerecords professionals should recognize that disclosure of such informationmust be handled carefully to assure protection of patient privacyand compliance with state law. Laws that permit patient access tomedical records conflict with adoption laws that require the sealing ofcourt records to protect the privacy of the biological parents. Becauseof this policy conflict, healthcare organizations responding to a requestfor information relating to adoption may be presented withdilemmas requiring a difficult weighing of competing interests.To assistin the formulation of an appropriate response to such requests,healthcare records professionals, in consultation with legal counsel,should develop policies and procedures to address disclosure of adoptioninformation.In developing policies and procedures in this area, health informationprofessionals may be interested in relevant recommendations from theAmerican Health Information Management Association (AHIMA). 128With respect to disclosure of adoption records information, AHIMAsuggests that healthcare records professionals consider the followingpolicies:• Refer requests for records information from biological parents to theagency that handled the adoption; biological parents of a child127N.Y. Dom. Rel. Law § 114(4).128American Health Information Management Association (AHIMA), “Practice Brief:Disclosure of Health Information,” Journal of AHIMA 67 (9) (1996).