Printable hospital template
Hospital patient-record request tracker
Track an authorised request for a copy of records from receipt through scope checks to delivery, with unresolved questions visible to responsible staff.
- Written by
- RizCare
- Published
- Last reviewed
RizCare's suggested worksheet. Adapt to your hospital. https://riz.care/library/templates/clinic-record-request-tracker
For the staff member assigned to coordinate record requests.
A request for records can be received before the hospital knows who may authorise it or which documents it covers. Logging its arrival prevents it being forgotten. It does not authorise disclosure.
Your hospital's responsible person must decide identity, authority, scope and any legal obligations under the applicable policy. This tracker supplies no statutory deadline, entitlement decision or retention period.
Print this page or save it as a PDF from your browser. The print layout contains only the blank worksheet and its completion note. Fill it in within your hospital.
Practice: ____________________ Prepared by: ____________________ Date: ______________
| Request / received | Scope reference | Authority decision | Preparation check | Delivery / next action |
|---|---|---|---|---|
| Blank entry | ||||
| Blank entry | ||||
| Blank entry | ||||
| Blank entry | ||||
| Blank entry |
Keep completed copies with the staff authorised to use them.
How to use it
Record the request without releasing anything
Give the request a reference and date. Note its stated scope and link to the protected record containing requester details. Route it to the person responsible for reviewing authority. Keep a request awaiting clarification visibly open instead of asking reception to improvise a decision at the counter.
Confirm the approved scope
Record the decision and the approved documents by reference. If only part of a request is approved, make the boundary clear to the person preparing the copy. Have an authorised reviewer check that the material belongs to the correct patient and matches that scope. Questions about third-party information or legal restrictions belong with the responsible reviewer.
Account for delivery
Agree the permitted delivery method and check the recipient through the hospital's procedure. Record preparation separately from dispatch and receipt confirmation. If delivery fails, retain the failed outcome and next action. File completed copies and request records under the hospital's approved retention and disposal policy; do not leave spare copies beside the printer.
What each field means
- Request reference
- Keep the tracking reference stable across questions and delivery attempts. Avoid creating a second request simply because another staff member takes over.
- Authority status
- Write awaiting review, clarification needed or approved scope with the decision reference. The existence of a family relationship alone should not be treated as the recorded decision.
- Delivery outcome
- Name the evidence that the approved route was used, with the date and responsible staff member. Record a pending acknowledgement honestly rather than filling in a presumed completion date.
Completed fictional example
The fictional approval is an example of a completed local decision, not a statement of who is legally entitled to a record.
| Request / received | Scope reference | Authority decision | Preparation check | Delivery / next action |
|---|---|---|---|---|
| REQ-12 / 9 September | SCOPE-12 | Reviewer A / approved scope | Staff B checked | Approved channel; acknowledgement pending |
Related resources
Sources and review
The worksheet design and examples are RizCare's recommendations. The sources below support the background discussion; they do not endorse this form.
- Workflow Assessment for Health IT Toolkit (Agency for Healthcare Research and Quality). Read 9 September 2026.