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
Doctors
Medical Records

Does a retiring doctor need your permission to transfer your medical records to another doctor?

Yes, it is in fact legal, at least under HIPAA. Any transfer of medical information between Providers (the legal term for caregivers) that is in support of the patient's healthcare is legal without patient authorization.

The patient can, however, request that such medical records Not be sent, if they so wish. In this rare case, the doctor has 30 days (45 with extension) to show cause to deny the patient's request, or must comply.

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Health
Medical Records

Who has access to your medical records?

  1. You, yourself, may access your own medical records (except for -- maybe -- a psychotherapists notes). This may require a request from you in writing, or it may not.
  2. Healthcare providers may request access to your record without permission, assuming they're treating you. You may request that your records not be passed along, but this request is not a requirement.
  3. Payers -- your insurance company, for instance, may request some of your medical records in order to process payment or billing. They are entitled to "the minimum necessary" amount of info required to do their job.
  4. Your medical records may be viewed in the process of "Operations", so the IT department in a hospital, for instance, may need to see some of your records in order to print them out. They are not allowed to reveal anything therein.
  5. Your records may be subpoenad by a court of law or a grand jury. You have the right to request the court seal your records after deliberations. The court will almost always comply.
  6. Healthcare providers may offer the relevant parts of your record to law enforcement in the event they are subpoenad to do so, or as supporting evidence in reporting a crime they are legally required to disclose.
  7. Covered Entities (who have legitimate copies of your healthcare records) have the option to reveal those records (except psychotherapy notes) to police with an Administrative Letters.
  8. Covered Entities may optionally reveal your records to law enforcement if said revelation is in the interests of National Security (although this clause is legally delicate and, barring an accompanying court order, likely will not stand the first challenge).
  9. If you are deceased, your survivors may petition the court to open your closed records. This is not always done.
  10. Any medical data about you may be revealed to or by anyone as long as the data being revealed does not include Individually Identifiable Healthcare Information (IIHI). So data can be revealed if nothing in the dataset can be used to specifically identify you. For instance, it's okay to say a patient was treated for the common cold in January, but NOT okay to say your name, birthdate, address, driver's license number, etc.

Added: And. . . of course, to anyone you specifically name in writing.

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Health
Law & Legal Issues
Medical Records
Health Insurance Portability and Accountability Act (HIPAA)

Does hipaa affect the patient's access to their own medical record?

Yes it does

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Antibiotics
Medical Records

What is mode of action by cefixime?

bacterial cell wall synthesis inhibitor

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Medical Records

Are electronic medical records protected as well as regular ones?

All electronic medical records should be secured and encrypted to ensure privacy of the patients. It is important to speak to your local health providers and discuss whether your information is secure if this worries you.

Health Insurance Portability and Accountability Act of 1996 (HIPAA) Rules and CMS' Meaningful Use requirements includes protecting the confidentiality, integrity, and availability of health information in EHR. Failure to comply would be costly and practitioners will be held responsible/liable with the consequence of lump fines as penalties in doing so.

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Medical Records

How long should you maintain a 13 year old girl's medical records if the statute of limitations in that state is 3 years and the age of the majority in that state is 21?

The child's medical records should be maintained by the parent until she's old enough - after that it's her own responsibility.

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Health
Law & Legal Issues
Medical Records

Does Patient have rights to their medical records?

Of course. Patients have complete right to accessing their medical records. Even more so with the 2014 ONC criteria for Electronic Health Records (EHR) and Meaningful Use Stage 2 where physicians have to ensure that at least 5% of their total registered patients access their medical data from their patient portals. While the usage of patient portals was not so common earlier, because of limited functionality, they have been continuously worked upon by healthcare organizations and are now much more usable. Patients can now see their Summaries of Care thanks to the universal CCD/CCR format which also allows patients to View, Download and Transfer their care summaries to any other physician they choose to. This is something truly revolutionary and will not only give patients more access to their medical records but also make them more engaged in their care.

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Law & Legal Issues
Medical Records
Health Insurance Portability and Accountability Act (HIPAA)

Does HIPAA protect the right to access medical records even if the medical bill has not been paid In other words can a medical provider deny access to your own medical records if you owe money?

HIPAA allows patient access to their own medical record, with very few exceptions. Failure to pay the bill is NOT one of those exceptions.

Added: HIPAA restricts and prevents the dissemination of your medical records without your knowledge and approval. There is no provision within it which allows a medical provider to hold your records "hostage" until you pay their bill.

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Mental Health
Alcoholism
Medical Records

How many veterans have died in alcohol related deaths in 2011?

858687
Hospitals
Doctors
Medical Records

Should patients folder be kept at hospital or be given to them to keep themselves?

In Canada, its not unusual for a doctor/dentist to illegally refuse a patient access to their file, so I'd vote for "give it to the patient to keep."

Another answer:In America, the caregiver must keep their own copy of patient records regardless. It is however a good idea for the patient to get their own copy and occasionally update it. The healthcare provider is allowed to charge a "reasonable amount" for reproduction fees, so you'll want to update your copy of the file occasionally.
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Medical Records
Health Insurance Portability and Accountability Act (HIPAA)

Is True or false the hipaa and security rules dictate that all who may come into contact with protected health information go through training on hipaa policy?

true

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Health
Doctors
Medical Records

Your doctor retired and you need your medical records transferred Is it legal for the previous medical group to charge to transfer records to your new doctor?

If the records are requested by your new Medical office, they should not charge you for them.. If you are picking them up.. normally they charge a fee and something like one dollar per page. If you can, have your new Doctor request the records. They should not charge for that.

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Health
State Laws
DIY Projects
Medical Records

How do you obtain permission to access medical records?

For your own records, you may sign an ROI (release of information) form. You may have to pay for copying costs, but that should be all.

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Criminal Law
State Laws
Medical Records

Does a probation officer have the right to medical records that could incriminate you?

With a court order for their release from the doctor or medical facility, yes, they do.

636465
Medical Records

What kind of statement is it if a carer just writes slept well?

Critical

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Medical Records

How long do medical information release forms valid?

one year

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Relationships
Medical Insurance
Medical Records

How do I obtain my husband's medical records?

Under the data protection act everyone has the right to view there own medical records.

Unless your husband is very unwell or has passed away you may not have the rights to view them without his permission. However in certain circumstances you can ask permission from the hospital of current or last admission.

Hospitals normally store records on site. Be patient as it may take a few days/weeks as a qualified member of medical staff may have to check the documents for errors before you can view them.

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Laboratory Testing
Medical Records

What if your ast blood test is 11?

normal

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Conditions and Diseases
Medical Records

What is the world's most rarest disease?

A disease no one has published about, barely anyone (if anyone) knows about it and probably only one person in the world has it would be the answer. It is hard/ impossible to know the rarest disease because that implies that practically nobody knows it... I do not think my explanation is clear but i hope you understand the point I am trying to get to.

If you have to do a project or something of the type about a rare disease I was reading about people who react badly to water on their skin this morning. It is very rare and sounds very interesting. Maybe something you would like to look into?

Also, saying the most rarest is not real English. Saying rarEST implies it is the most rare. Just taught you should know. I used to always make that mistake :)

495051
Medical Records

Release of protected health information to Emergency Departments is not limited by the Minimum Necessary Standard because the disclosure is for treatment True or False?

true

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Illinois
Business and Industry
Tax Audits
Medical Records

Why do records need to be kept within a workplace?

Records are kept in the workplace to document what was done and why, in case a tax issue arrises or a transaction is questioned. If someone wants to sue the business for something, then the business has records that show what was done, by whom, and when. Workplace records also document when maintenance or repairs were done, to help people remember when they may be needed next. And all of these records can help when the person who did the work moves to another town and someone else has to figure out what needs doing and how it used to be done.

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Medical Insurance
Job Training and Career Qualifications
Electronics
Medical Records

What are the Advantages of Medical Transcription combined with Electronic Medical Record?

When the Electronic Medical Records (EMR) were being adopted by the industry about 4-5 years back, most of the experts and analysts thought that they would eliminate Medical Transcriptions and would make physicians more of a computer-operated robot who just focuses on his monitor rather than the patient. However, over the years, physicians have realized that the need to document the encounter on medical transcriptions is of paramount importance. Quite a few physicians rely on documenting encounters on medical transcriptions with their staff members documenting the same in the EMR later on. Data can be entered in an EMR via two methods: direct entry by the physicians through point and click templates or using SOAP notes. This really makes creating a medical transcription a breeze as compared to duplication of work in the paper-based process and the hassle of writing everything by hand. Most present-day EHRs can also receive dictation by voice to create medical transcriptions.

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Law & Legal Issues
Medical Insurance
State Laws
Medical Records

When do medical records become public?

They are never public domain. They can only be disclosed in the event of the patient making the records public.

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Mental Health
Criminal Law
Medical Records

Does military check medical records?

Of course! They want to make sure that you are healthy and fit enough to undergo service.

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Health
Law & Legal Issues
Medical Records

How long do you keep medical records for patients in Colorado?

As with any medical record the federal law requires 7 years from the date of occurance. If it is a minor until the age of 21. As with any medical record the federal law requires 7 years from the date of occurance. If it is a minor until the age of 21.

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