Medical Records

Medical records are legal, written records concerning a patient's medical history, psychiatric history, chief complaint, symptoms, assessment and testing, diagnoses, symptoms, treatments and procedures, medications, and outcomes or responses. All medical professionals are required to document information in their patients' medical records. This category includes the common medical and legal forms patients must complete, what information might be written into a patient's record, how to obtain a copy of your patient record, and how to correct errors in your medical or mental health record.

2,060 Questions
Health
Medical Insurance
Medical Records

How would you locate medical records from 1960?

State laws usually only require holding them for a few years so they may no longer exist. The only way would be to contact the entity that provided the care and find out where the records are if if they are kept that long.

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Health
Law & Legal Issues
Medical Insurance
Medical Records

Who can see your medical records?

Under HIPAA regulations, only you and your immediate caregivers, and they are bound by law not to disclose them to any unauthorized person. Exceptions: If you are a minor your parent/guardian has access. They can be disclosed to person specifically authorized by you. They can be released under court order.

You may also find some HIPAA certified EMR vendors like CureMD, Allscripts and eclinical works where you can get more detailed information about this regulations.

Correction:

In the US, under HIPAA, here's who can see your records -- roughly:

  1. You can, in full -- unless:
    • You can't see your Psychotherapy notes.
    • If you're in prison you cannot demand these records.
    • If showing you these records will put someone else in danger, that part of the record may be redacted.
    • If the Covered Entity (CE) is preparing litigation involving you, that part of your records can be witheld.
    • Records can be withheld in the interest of National Security (never been done yet, that I'm aware of).
    • Healthcare Providers can see all the records without restriction (unless YOU restrict it see below).
    • Payers (Insurance companies, etc.) can see your records, but only the Minimum Necessary to do their job.
    • Clearing Houses (companies that take data from the doctors and organize it in a way the Payers can work with) can see your records, but only the Minimum Necessary.
    • Medicare can, as a Payer for the most part.
  2. Other CE's can see your records in the course of providing you healthcare, and ONLY in that event.
  3. Business Associates (BA's) under a BA contract that binds them to HIPAA may see the minimum necessary. These are companies employed by CE's that are not themselves CE's.
  4. The Court or Grand Jury can subpoena your records.
  5. Law Enforcement may write an Administrative Letter that theoretically allows the CE to reveal your records to them. This does not require a warrant anymore; only "good faith" on the officer's part. I am not aware of this actually having been done.
  6. The Scty. of the Department of Health and Human Services (DHHS) may see your records as part of administering to HIPAA and related complaints under HIPAA.
  7. If you've voluntarily joined a research study, they can see the part of your records pertaining to the study -- and you can't.
  8. Anyone you specifically allow in writing may see your records (this is called an Authorization and is a bit tricky to write).
  9. Your Personal Representative (in the Medico/Psyche sense), if you have one, may see all your records and has all your rights too.
  10. Whoever has your POwer of Attorney, if anyone does, may see some of the records. Usually, the PoA is also Personal Representative, which clears the matter up.
  11. Your guardians, if you have any, may see your records in most States. Parts are redacted in some States that apply to pregnancy, AIDS, or anything wherein the information in the records may cause the patient harm.
  12. Law Enforcement may see your records (minimum necessary) as part of an investigation of a crime you are suspected of, in the event that the crime occurred in view of the CE.

Note this is is only a brief summary of who is allowed legally to view your records.

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Definitions
Medical Terminology
Heart Disease
Medical Records

What does unremarkable mean in medical terms?

adj. unremarkable - 1. Lacking distinction; ordinary.2. found in the ordinary course of events; "a placid everyday scene"; "it was a routine day";

In medical practice, when nothing UNUSUAL found, occured or happened, its UNREMAKABLE

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Definitions
Medical Records

Why legibility is important to medical records?

because it's another person's life your dealing with. You could seriously hurt them or even kill them if you can't read the record.

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Health
DIY Projects
Medical Records

How do I get false information taken out of my medical records.?

If you are in the United Kingdom you cannot remove information from your medical records. (This is obviously regarding your actual medical notes and history, not your contact details etc; those you DO of course have the right to have altered).

However, you have a right to have a note added to your records that states the correct facts and points out what is wrong.

In the US, probably lawyer up or something. Enough money buys you anything you want regardless of the law I'm sure. ;-)

209210211
State Laws
Florida
Medical Records

How long do Florida doctors have to keep medical records?

7 years

187188189
Law & Legal Issues
Medical Records

Do medical records qualify as consumer reports under the Fair Credit Reporting Act and is there legal precedent stating such?

This information can be located @ www.ftc.gov, there you will be able to search your information regarding the medical records.

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Divorce and Marriage Law
Medical Records

Can an ex husband request his ex wife's medical records?

No. A husband cannot request a copy of their wife's medical records without her authorization. An ex-husband has absolutely no right to any private records nor any other "rights" regarding their ex-wife.

No. A husband cannot request a copy of their wife's medical records without her authorization. An ex-husband has absolutely no right to any private records nor any other "rights" regarding their ex-wife.

No. A husband cannot request a copy of their wife's medical records without her authorization. An ex-husband has absolutely no right to any private records nor any other "rights" regarding their ex-wife.

No. A husband cannot request a copy of their wife's medical records without her authorization. An ex-husband has absolutely no right to any private records nor any other "rights" regarding their ex-wife.

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Medical Terminology
Medical Records

What is retrosternal?

retrosternal (in lat. retro-sternalis) means behind the sternum (sternal bone)

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Medication and Drugs
Medical Records

What drugs are opanas made of?

Opana is the brand name for oxymorphone, a moderate strength painkiller.

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Medical Records

Is medical records an example of a source of law?

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Cars & Vehicles
Medical Records

What are the guide for safety and protection against accident?

don't be over-speed and not to jump traffic signals

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Medical Records

Why is procrastination a hindrance with patients' medical records?

Depends on who's asking. If you're the patient's healthcare provider and you delay providing medical records to either the patient or another healthcare provider who is treating her, you risk of running afoul of HIPAA, which requires a reasonably prompt response time, and additionally run the risk of a lawsuit if the delay causes a problem with the patient's treatment.

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Health
Medical Records

Who owns patients medical records?

Who owns the patient medical record

001
North Carolina
Medical Records

Is it legal to charge for medical records in North Carolina?

North Carolina General Statute Section 90-411 permits the following charges: Search, Handling, Copying and Mailing Costs Up to $10.00 Certification Fee Up to per record $9.32 Copying Costs for Records in Paper Form Per page for pages 1-25 $0.75 Per page for pages 26 - 100 $0.50 Per page for pages over 100 $0.25 The HIPAA Privacy Rule prohibits the charge for Search, Retrieval and Other Direct Administrative Costs from being assessed against the patient or the patient's personal representative who requests medical records. The HIPAA prohibition does not apply to requests by other persons.

The HIPAA Privacy Rule prohibits providers from charging to convert medical records into a form or format requested by the individual, if it is readily producible in such form or format, or into a readable hard copy form or other agreed upon form or format. However, if the individual wants a copy of a non-paper medical record, then a hospital may charge a reasonable, cost-based fee for copying the record, including the cost of supplies and copying labor.

Where someone other than a patient or their personal representative requests records, physicians may charge a reasonable fee (currently $10.00) to search for, handle and copy requested records. However, actual mailing costs may always be charged, regardless of who the requester is. The fee constitutes a minimum charge. It does not apply when the actual copying charge exceeds the minimum.

A physician may charge to prepare a health record summary.

A physician or hospital may not assess a copying charge where the requester is applying for Social Security Disability or Income benefits.

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Health
Genealogy
Medical Records

How do you find medical records on someone who died in early 1900s?

Nearly IMPOSSIBLE to do that. None of them are on any computer, and if they still exist, they are paper and in a dusty file cabinet some place in a basement. Most have been long destroyed long ago. An outside chance would be if you could find the doctor's descendants and if they happened to keep the records. A death certificate may also show cause of death.

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Health
Law & Legal Issues
Medical Insurance
Medical Records

How long are medical records kept in Indiana?

medicalrecordrights.georgetown.edu/stateguides/in/in.pdf Medical records must be kept at least 7 years from the date they were created. Some healthcare providers keep them longer.

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Medication and Drugs
Medical Records

Does a doctor have to release medical records if you owe them money?

Yes they do. Under HIPAA, the caregiver may not withhold patient information because of non-payment.

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Medical Records

What statute states a doctor can withhold your records because of money due?

No such statute exists and, if one did, HIPAA would overrule it at the federal level. It is specifically illegal to withhold medical records in order to collect payment.

959697
Organizations
Doctors
Medical Records

How do you report a doctor to the American Medical association?

First - The AMA does not have anything to do with reporting a doctor regarding

conduct etc. The AMA is an organization, which allows doctors (if they choose so) to

become members of their (AMA) organization. The AMA then delivers medical data regarding the medical industry.

If you want to report a doctor regarding misconduct, the best thing to do is contact

your state medical board (http://www.mdnationwide.org/choose_a_doctor.htm) by

writing a detailed, nice, professional "Registered or Certified Letter" regarding your

situation.

394041
Retirement Planning
Social Security
US Congress
Medical Records

Is it true that 24000000 dollars for new electronic medical records processing for your congressmen and senators will be taken out of Social Security?

The money came from the stimulus and is for speeding up disability claims. See link.

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Medication and Drugs
Medical Records

What is the meaning of ss in medical records?

Usually, it's referring to "signs and symptoms" but it should be written "sg" and "sx". I've also seen it "s/s."

878889
Aging and Life Extension
Hospitals
Medical Records

Why are tooth fillings are often made of gold or porcelain?

Hi,

Gold and porcelain have good resistance to staining. These materials are nonreactive and they do not rust or corrode. There properties include low thermal conductivity and expansion and they are resistant to wear.

858687
Insurance
Life Insurance
Medical Records

What are a Life insurance company's rights to obtain medical records?

when you sign the application there is a statment or often a separate signature page that is a waiver to give them permission to access your records. so basically they have complete legal rights to obtain your records. but they are also bound by privacy laws and cant disclose this info to anyone, not even the agent that sold you the policy get to see the full records.

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Cardiovascular Health
Medical Insurance
Medical Records

What are the two approaches used to insert devises that electrically shock the heart into regular rhythm?

epicardial and transvenous

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