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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
What color pen should medical records be written in?
I was told by my colleague that we should write in black pen. I don't know the reason behind it though. If it's up to me, any color should be fine as long as the writing is illegible. Even if people write in black pen, if it's unreadable then what's that point. Writing classes should be included in medical courses.
What is the meaning of SOMR in medical records?
S = Source
O = Oriented
M = Medical
R = Record
A format of using Source approach
example
Radiology Report
Laboratory Report
Surigical Report
the reason for not letting a service user see their record is because some people might have mental problems, and therefore seeing their records may cause them to have problems. also a service user who has memory problems and should not be forced to remember, they are not allowed to see their records. all service users have the right to see their information but some shouldn't if it will affect their health
Who has access to your medical records?
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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).
- If you are deceased, your survivors may petition the court to open your closed records. This is not always done.
- 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.
Disadvantages of manual medical records?
Can be use by only one person at the time.
Easily misplaced or misfiled
Equipment and storage required
More susceptible to error.
Importance of maintaining security and confidentiality?
Security and confidentiality are two very important things. Without them people would not be OK with bank use or anything.
Pus cells in clumps are often detected in the urine. This is normally a sign of a bacterial infection. It could be a urinary tract infection, kidney infection, or a sexually transmitted disease. It is best to get the opinion of a licensed physician to get an accurate diagnosis.
name and identification
name and id
How can you find archived medical records?
Archived Medical records are stored in the Hospital via their medical records section. They store archived one's for research expecially for those medico-legal cases.
How do you get your own medical records?
Everyone has the right to obtain their own medical records. Simply contact your physician's office and request a copy of your records. You'll have to pick them up from the office and sometimes there's a small fee.
Should corrections to a medical record be date and time stamped?
It's preferable, but not totally necessary.
How long should medical records be kept?
Medical records should be kept for as long as required based on the type of record, and federal/state laws.
What are the procedures to obtaining your own medical records?
All you have to do is go to your doctor and request a copy of your medical records. They are regulated by HIPAA to give u a copy. They may charge to make copies but only if its reasonable. Usually the office will have a form you sign stating they gave you a copy ect. HHS.ORG shows HIPAA aka Health Insurance Portability and Accountability Act Sec. 164.524 Access of individuals to protected health information. I hope this was helpful.
How do health care facilities use Electronic medical records?
Applying electronic medical record systems in your practice isn't as easy as taking the software program right from the box and installing it. The truth is, that is far from how it really works. It's quite the daunting job for the majority of practices and the federal government estimates that the EMR failure rate tops out at 30 percent.
What is MONO in a hematology test?
The term MONO when used in hematology tests refers to monocytes, which are a form of white blood cells or leukocytes. The monocyte is the largest of the leukocytes and form part of the human innate immune system.
Nancy Pietrobono is attached to the Westchester Medical Center, Westchester, New York.
Can you find medical records from kings county hospital br oklyn ny FROM 1949 to 196o?
No. They only keep records up to 20 years back.
How do you get your medical records?
ok so what you should do is go to your normal health phisicican and ask for your medical records and he/she should be able to print them out for you
Do you mean release your PHI to the insurance claims company?? Your healthcare provider generates your PHI, so they already have it.
Yes, you should release the info. In order to receive workmen's compensation, you need to have the records to prove that your claim that your medical condition is due to an accident/injury at work.
The HIPAA Act, was enacted by Congress to insure privacy protection of medical records. Medical information can be given out, only with written permission of the person. This however, does not mean that any collection process, judgment, etc. by a hospital, doctor, agency, and so on, cannot be included in the CR.
They might be.
My first response was to say no, and quote the definitions directly from the FCRA. But, upon reading them, I would prefer you interpret them for yourself, or better yet, refer to an attorney familiar with reading law.
FCRA 15 USC 1681a sec. 603(d)(1)(2) and (3) which refers to sec. 604(g)(3)...that is where it gets sketchy (for me) and what MIGHT apply to your question.
You can print yourself off a copy of the FCRA at www.ftc.gov
Sorry to be evasive, but if you need an answer, it is best to get a correct one.
How long are doctors required to keep medical records in Connecticut?
How long should a medical record be retained
What is the statute of limitations on medical records?
There is not a statute of limitations for information. There may be rules about how long records have to be maintained. It is usually based on how far back a lawsuit can go and whether there may be tax related information in them.
