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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.

962 Questions

How long do NF in Delaware keep medical records?

In Delaware, healthcare providers are required to keep medical records for a minimum of seven years from the date of the last treatment or the patient's last encounter. For minors, records must be retained until the patient turns 18, plus an additional seven years. However, specific practices may have their own policies that extend beyond these minimum requirements. Always check with the individual provider for their specific retention policy.

What industry uses medical records or medical billing and codeing people?

The healthcare industry primarily employs professionals in medical records and medical billing and coding. These roles are essential for managing patient information, ensuring accurate billing, and facilitating reimbursements from insurance companies. Medical coders translate healthcare services into standardized codes, while medical record technicians maintain and organize patient documentation. Together, they play a vital role in the efficient operation of hospitals, clinics, and other healthcare facilities.

How long should veterinary medical records be kept on deceased patients in Florida?

In Florida, veterinary medical records for deceased patients should generally be kept for a minimum of two years after the animal's death. This retention period aligns with the Florida Veterinary Practice Act. However, it is advisable for veterinarians to retain records longer if they pertain to any ongoing legal or liability issues. Always check with local regulations and professional guidelines for specific requirements.

What does low attenuation of the ovarian mass mean?

Low attenuation of an ovarian mass on imaging, such as a CT scan, typically indicates that the mass is less dense than surrounding tissues, which may suggest it is fluid-filled or cystic in nature. This can be associated with benign conditions like ovarian cysts or functional ovarian masses. However, low attenuation can also occur in certain malignant tumors, so further evaluation and correlation with clinical findings are often necessary for an accurate diagnosis.

What does Unremarkable mean in a medical report?

In a medical report, "unremarkable" refers to findings that are normal or typical, indicating that there are no significant abnormalities or issues observed during the examination or imaging. It suggests that the results do not indicate any cause for concern and are consistent with a healthy state. This term helps healthcare providers convey that there are no unusual or noteworthy findings to report.

Who can give consent for information to be released from a patients medical records?

Consent for information to be released from a patient's medical records typically must be given by the patient themselves, or by a legally authorized representative if the patient is unable to provide consent due to incapacity or age. This may include parents or guardians for minors or individuals with power of attorney for adults. In some cases, specific laws may allow for the release of information without consent, such as in public health emergencies or legal proceedings. Always check relevant regulations and institutional policies for compliance.

What disease is involved when people can't let go of what the objects they hold?

The condition you're referring to is likely hoarding disorder, which is characterized by persistent difficulty in discarding or parting with possessions, regardless of their actual value. This behavior often stems from emotional attachment to the items or a fear of losing important memories. Individuals with hoarding disorder may experience significant distress and impairment in daily functioning due to their inability to let go of objects. Treatment typically involves therapy, particularly cognitive-behavioral approaches, to help address the underlying issues and improve decision-making regarding possessions.

How long have written records approximatly exsited for?

Written records have existed for approximately 5,000 years, dating back to around 3,200 BCE with the emergence of cuneiform script in ancient Mesopotamia. This early form of writing allowed for the documentation of transactions, stories, and administrative details. Since then, various writing systems have evolved across different cultures, contributing to the preservation of human history and knowledge.

What is degenerative endplate changes in the c5-c6?

Degenerative endplate changes at the C5-C6 level refer to alterations in the vertebral endplates, which are the interfaces between the vertebrae and intervertebral discs in the cervical spine. These changes often result from aging or wear and tear and can lead to conditions such as disc degeneration, osteoarthritis, or spinal stenosis. Symptoms may include neck pain, stiffness, or radiating pain in the arms, depending on the severity and associated nerve involvement. Diagnosis typically involves imaging studies like MRI or X-rays to assess the extent of degeneration.

How long do you need to keep juvenile medical records?

Juvenile medical records should typically be kept until the individual reaches the age of majority, which is usually 18 years old, plus an additional period defined by state or local regulations. Many practices retain these records for at least 5 to 10 years after the individual turns 18 to account for potential legal or medical needs. It’s important to check specific state laws, as requirements can vary. Always consult legal counsel or a professional for guidance tailored to your situation.

Why are paper medical records more secure than eletronic health records?

Paper medical records can be considered more secure than electronic health records (EHRs) in certain contexts because they are less susceptible to cyberattacks, such as hacking or ransomware. They are stored in locked file cabinets, limiting access to authorized personnel only. Additionally, paper records do not rely on technology that can fail or be compromised, thus avoiding risks associated with software vulnerabilities and data breaches. However, it's important to note that paper records have their own security challenges, including physical loss or damage.

What does O mean when documenting in patient medical records?

In patient medical records, "O" typically stands for "Objective," referring to observable, measurable data collected during a patient's examination. This includes vital signs, lab results, imaging studies, and physical examination findings. The "O" component is part of the SOAP format (Subjective, Objective, Assessment, Plan) used to organize clinical information. It provides a factual basis for assessing the patient's condition and planning treatment.

How do Health and Human Services get access to medical records?

Health and Human Services (HHS) can access medical records through various means, primarily for regulatory and enforcement purposes. This may include audits, investigations, or compliance checks related to healthcare laws and regulations, such as HIPAA. HHS may obtain records through authorized requests, subpoenas, or partnerships with healthcare providers, ensuring that patient privacy is maintained in accordance with legal standards. Additionally, entities under HHS, such as the Office for Civil Rights, may access records to ensure compliance with health privacy regulations.

Describe how clients records should be held and maintains?

Client records should be securely stored and maintained to ensure confidentiality and compliance with data protection regulations. This involves using secure systems for both physical and digital records, implementing access controls to limit who can view sensitive information, and regularly updating and backing up data. Additionally, records should be organized systematically for easy retrieval and properly disposed of when no longer needed, following established retention policies. Regular audits should also be conducted to ensure compliance and identify any potential security vulnerabilities.

What is a source oriented medical record?

A source-oriented medical record (SOMR) is a type of patient record that organizes information by the source of the data, such as different healthcare providers or departments. Each section of the record is dedicated to a specific source, making it easy to locate information from doctors, nurses, and ancillary services. This format can enhance communication among providers but may lead to fragmentation of information, as it does not emphasize a chronological order of patient care.

How long should federal medical records be kept?

Federal medical records should generally be kept for a minimum of six years after the last date of service, as mandated by the Health Insurance Portability and Accountability Act (HIPAA). However, specific retention periods can vary depending on state laws and the type of records involved. For example, records related to minors may need to be kept longer, often until the minor reaches the age of majority plus a specified number of years. It's important for healthcare providers to be aware of both federal and state regulations regarding record retention.

Can a debt collector see medical records?

Generally, debt collectors do not have access to your medical records. Medical records are protected by privacy laws, such as the Health Insurance Portability and Accountability Act (HIPAA) in the United States, which restricts the sharing of personal health information. However, a debt collector may know that you owe a medical debt if the healthcare provider has reported it, but they cannot access the details of your medical records without your consent.

What is epidemic cyst in man?

Epidemic cysts in humans, often referred to as epidermoid cysts or sebaceous cysts, are benign growths that typically occur within the skin. They form when hair follicles become blocked, leading to the accumulation of keratin and other debris. While they are usually harmless, they can become infected or inflamed, causing discomfort. Treatment options include surgical removal if they become bothersome or symptomatic.

What are some of the technologies used in the development and implementation of the EHR?

Electronic Health Records (EHR) systems utilize various technologies, including cloud computing for data storage and accessibility, and interoperability standards like HL7 and FHIR for seamless data exchange between different healthcare systems. They also incorporate advanced data encryption and cybersecurity measures to protect sensitive patient information. Additionally, EHRs often employ machine learning algorithms for data analytics and decision support, enhancing clinical workflows and patient care. Lastly, mobile applications and user-friendly interfaces are developed to improve accessibility for healthcare providers and patients.

How long should medical records for an adult be kept before being destroyed and explain how they should they be disposed of?

Medical records for adults should typically be kept for at least seven years after the last treatment date, although this can vary by state or country regulations. After this retention period, records should be securely destroyed to protect patient privacy, often through shredding paper documents and permanently deleting electronic files. It's important to follow specific legal guidelines and institutional policies regarding the disposal of medical records to ensure compliance and confidentiality.

What reasons would a soldier not receive a disclosure that an outside party has reviewed their medical record?

A soldier may not receive disclosure about an outside party reviewing their medical record due to privacy regulations, such as the Health Insurance Portability and Accountability Act (HIPAA), which limit the sharing of medical information without patient consent. Additionally, military regulations may restrict disclosures for operational security or to protect sensitive information. If the review was part of a legal investigation or internal audit, the soldier might also not be informed to ensure the integrity of the process.

What is a place called where government records are kept?

A place where government records are kept is typically called an "archive" or "records office." These facilities preserve and manage documents such as legal records, historical documents, and various public records for accessibility and research purposes. They ensure the protection and proper organization of these materials for current and future use.

What is an interval note on the patient medical record?

An interval note in a patient medical record is a concise documentation of a patient's status and any changes since the last visit or assessment. It typically includes updates on symptoms, treatment responses, and any new findings, providing a snapshot of the patient's progress or condition over a specific period. Interval notes help healthcare providers track the evolution of a patient's health and inform ongoing treatment decisions.

How do you find value of your old long playing records?

To find the value of your old long-playing records, start by researching their condition and rarity. Check online marketplaces like eBay, Discogs, and music collector forums to see current listings and completed sales for similar records. Additionally, consult price guides or collector's books specific to vinyl records. Finally, consider reaching out to local record shops or appraisers for expert insights on your collection's worth.

Can your husband access your medical records without your permission?

In most cases, a husband cannot access your medical records without your permission due to privacy laws like the Health Insurance Portability and Accountability Act (HIPAA) in the United States. Medical records are protected information, and healthcare providers require explicit consent from the patient to share that information with anyone, including family members. However, there may be exceptions in certain situations, such as emergencies or if the patient is incapacitated. It's always best to check with your healthcare provider for specific policies regarding access to medical records.