GRADED
TRIAL
# 1
GRADED
TRIAL
# 2
NOTES
1. ✦ Gather all supplies and
information. Log in to the EHR,
and access the medical records
request screen.
2. ✶ Verify the identity of the patient if
you have not already done so.
3. ✦ Confirm with the patient the
information requested, the
intended recipient, and the
recipient’s address.
4. ✦ Fill in the corresponding fields
on the form or screen for the
patient’s name, the information
requested, and the name and
address of the intended recipient.
5. ✦ Ask the patient to sign and date
the form in the designated place.
6. ✶ Visually verify the signature and
date to ensure the form was
completed correctly.
7. ✦ Inform the patient approximately
when the information will be
released, according to oce
policy.
8. ✦ If the patient is not present, print
out the form and highlight the
spaces to be completed. Place
the form and return instructions in
an envelope, apply postage, and
mail.
9. ✶ Save the screen in the EHR, and
confirm that the request is to
be sent to the medical records
department. If using a paper form,
route the completed form to the
medical records department.
POINT VALUE
✦ = 3–6 points
✶ = 7–9 points
Name: ________________________________________
Date: _________________________________________
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