The same principles are pertinent in the release of diagnostic studies such as lab work, x-rays, CTs or MRIs. Treat these studies in the same manner as the medical record. Do not give the patient the original record or study. To do so is comparable to giving the patient the original medical chart. Remember, the physician owns these documents. The patient owns the information the studies provide.

Let’s use imaging studies as an example. A treating orthopedic surgeon requests the x-rays. The radiology department sends them to the orthopedic surgeon. The radiology department should have a system for logging the studies out and for recording them when they return. Such a system should include a procedure to periodically retrieve any studies which have not been returned. These studies are maintained in the radiology department’s permanent files.

The treating orthopedic surgeon in this example should also have a system for logging the x-rays in, initialing them when he/she reviews them, and logging them out when they are returned to the radiology department.