Psychiatric Hospital Records

This guide will help you gather the psychiatric hospital records you will need to produce for an aviation psychiatric evaluation.

In the FAA Specification Sheet for a psychiatric examination, one of the core duties that the aviation psychiatrist must complete is:

A review of all available records, including academic records, records of prior psychiatric hospitalizations, and records of periods of observation or treatment (e.g., psychiatrist, psychologist, social worker, counselor, or neuropsychologist treatment notes). Records must be in sufficient detail to permit a clear evaluation of the nature and extent of any previous mental disorders.

RELEASE FORMS

Most hospitals prefer that you use their own release forms. You may be able to download a form from the facility’s website, if they have one, or you can call the hospitals medical records department (sometimes called Health Information Management) and ask about the records release procedure.

Please ask the hospital to send the records directly to my office. If a file instead comes to you by mistake, do not open the envelope but instead deliver it to me unopened. A broken seal on a records production taints the file and can require us to start over.

This is what counts as a full hospital record:

  1. Physician discharge summary
  2. Admission history and physical
  3. Psychosocial assessment/summary
  4. All mental health progress notes
  5. All physician notes and orders
  6. All laboratory testing data
  7. All nursing notes
  8. Emergency Department report, if any
  9. Psychological report, if any
  10. Counselor’s discharge summary, if any
  11. Substance use/abuse assessment, if any

There are three ways to have the clinic send records to me. The preferred way is to have the file produced on paper and mailed to me. The mail always arrives and I can always read the pages.

The next best way is to have the facility produce the records on some physical media. I can accept optical (e.g. DVD or CD) media or flash memory devices of all kinds. Files are occasionally corrupted, so I prefer paper, but this way usually works, too.

The third-best way to produce the file is by emailing the record to me. This would be the most efficient if it worked well, but some secure messaging protocols can block the facility from sending a record or me from receiving it.

Files CANNOT be faxed to me
. My server will block any fax more than a few pages and I will not know that the file has been blocked.

Most of the time, a psychiatric hospital record will not count as a psychotherapy record. But, if so, the information below can be useful to make sure your request is processed appropriately.

HIPAA rules gives special protections to psychotherapy records. Among the protections is that a therapist can refuse to release a psychotherapy file, without giving you a reason, unless a valid court order compels a release of the record. To address a few common concerns, please know that:

A summary of treatment, such as a hospital discharge summary, most of the time fails to meet the standard that previous treatment is reviewed in “sufficient detail” as described by the FAA in the specification sheet.

The record has the same HIPAA psychotherapy protection and exemption when held in this office as it does when kept by the originator. The file can be released only with your written consent or a court order.

I have an ethical obligation to de-identify my report so that my assessment does not reveal protected health information (PHI) of others. For example, I am not allowed to quote something from the psychotherapy record that inadvertently identifies any other person, such as a spouse, child, or companion.