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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
30 years
What is the definition for patient identifiable data?
In the US, the legally specified term is Individually Identifiable Health Information which, under HIPAA, is protected. Here is the text from the Privacy Rule, Definitions, section 160.103:
Individually identifiable health information is information that is
a subset of Health Information, including demographic information
collected from an individual, and:
(1) Is created or received by a health care provider, health plan, employer, or health care clearinghouse; and
(2) Relates to the past, present, or future physical or mental
health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and
(i) That identifies the individual; or
(ii) With respect to which there is a reasonable basis to believe the information can be used to identify the individual.
Is the admission and discharge dates of a medical record considered medical or clinical information?
Yes. the date itself is not, but once you tie it to a specific patient/client (whoever tehy asked about) & facility (because they had to call/write to you), you are now telling someone that patient "Smith" was at Hospital X on these dates. that would be a violation of privacy.
Micki F., RHIT
True
It is Ok to release information to emergency departments.
True
discharge summary
Where public records are kept?
Public records are created and filed at thousands of public offices and agencies throughout the country. These records are kept (stored) at those offices, which makes it difficult for people to get access to any records they need.
These public records are also stored electronically in various databases. Companies that provide public records reports (like people searches, background checks, reverse phone lookups, etc.) access these databases and pull the relevant information based on search criteria.
It is possible for someone to get physical copies of public records, but they could involve visiting several locations, waiting for various documents to be made available and paying administrative fees.
some cases the technical people who is responsible for updating there database is not doing thier job to update all record who is already expired,so do there job properly
The polyps are located and removed with a wire snare, ultrasound, or laser beam
Who is the only person that can authenticate the information in a patient's medical records?
The person who creates the data in the record
All of the above
When are patients not allowed access to their medical records?
In America, under the Health Insurance Portability and Accountability Act (HIPAA), patients are to be always allowed access to their entire and full medical record, with the exceptions as follows:
- Psychotherapy notes, which can be withheld if it is deemed to be in the patient's best health interests.
- If the patient is in a Correctional Facility.
- Information pertinent to a legal case between holder of the PHI and the patient.
- Health Information obtained as a result of research, during the course of said research (this would include the patient's agreement to participate).
- Information obtained from someone else other than a healthcare provider where such release would endanger the patient or the person who provided the information.
- When information included in the record was obtained under promise of confidentiality from someone else, and revealing the PHI would reveal the confidant's identity.
- When release of the PHI would endanger the life of the patient or other person (subject to review).
Note that a couple of these are pretty bizarre and pertain only to very specialized circumstances. For instance, if you're in a law suit with your doctor, she doesn't have to reveal her defense notes to you. However, using this as a means of not revealing ANYTHING in your patient records would be illegal as well as ridiculous.
For the most part, and in most instances, the patient is entitled to a full review of their own medical records.
Can insurance company make an individual sign a form releasing their protected health information?
They can't make you sign anything, but they can refuse to provide coverage.
Can a medical office release medical records to an atty if pt is work comp?
Yes. A Covered Entity (CE -- the caregiver) may release patient records to their attorney for purposes of obtaining payment, in which case they are allowed to release the "minimum necessary" to allow the process to work. Also, they may release subpoenaed records.
Most WC claim forms have a notation that you allow your doctor to release medical information pertinent to the claim as well, so you may have authorized the release yourself without noticing it.
Within 30 days for both dictation and filing.
Under HIPAA's Privacy Rule, a patient's consent is not required for:
- Usage or disclosure for treatment, payment or health care operations (TPO)
- Disclosure for marketing purposes
- Disclosure to business associates
- Court orders
How do medical records and health information technicians use probability in their job?
Medical records and health information technicians use probability in their jobs when calculating the number of charts to audit.
Collecting the maximum amount of PII/PHI needed to ensure the availability of information when requested.
