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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 is the difference between medical records and a hospital chart?

A hospital chart is based on a day to day basis,as to what medical records are is an accumulation of a hospital stay it is kept and stored.

Medical Records Clerk responsibilities?

A medical records clerk is responsible for the patients records or information regarding their cases. they store & filed the the records of the patients. They answers the inquiry of the patients.

Is it legal to email medical records?

Don't think so. It would be against the federal privacy act.

How can you get medical records if your doctor is dead?

Check with anyone who may have also had the records, such as your health insurance company, your doctor's partners, spouse, etc.

Is it possible to access medical records of a relative who died in the 1950's?

If you can prove that their patient is, in fact, deceased, and that you are the executor of their estate, probably yes. Your actual problem may be that records retention laws rarely require medical practitioners to retain inactive medical records that are that old.

What happens to the old medical records from Silas B Hayes Army Hospital at Fort Urd California?

Medical records of dependents were retired to the National Records Holding area Saint Louis. The military medical records went from installation to installation with the soldier, and then would be in the St. Louis National Archives with the personnel records.

Is it illegal to deny a patient a copy of his chart if he is unable to pay the fee to obtain it?

A patient with a chart is usually in the hospital. With that said, most hospital stays including the tests done for a patient are paid for by an insurance company. Since the hospital is already paid, it seems logical that a copy of the patient's chart should be given freely. It would seem to be a patient "right".

Do parents have rights to their children's medical records after they have lost custody?

Generally, the person who has legal custody or legal guardianship of the child has right to the child's medical records. A parent who does not have legal custody is not entitled to the child's medical records. Generally, they would need a court order to obtain them.

Generally, the person who has legal custody or legal guardianship of the child has right to the child's medical records. A parent who does not have legal custody is not entitled to the child's medical records. Generally, they would need a court order to obtain them.

Generally, the person who has legal custody or legal guardianship of the child has right to the child's medical records. A parent who does not have legal custody is not entitled to the child's medical records. Generally, they would need a court order to obtain them.

Generally, the person who has legal custody or legal guardianship of the child has right to the child's medical records. A parent who does not have legal custody is not entitled to the child's medical records. Generally, they would need a court order to obtain them.

What payrate does someone in the medical records field make?

If you work for a physician's office in New Hampshire, the starting pay is $10 an hour for someone without experience.

Describe how compliance plans correlate to different medical records documentation standards?

Whomever wrote the first response is an idiot... compliance plans are a MAJOR factor in the medical field.

Compliance plans correlate to different medical records documentation standards by investigating the files. Reviewers come to medical offices to make sure that things like billing and requirements of the patient are correct. An example would be something like this:

Men 50 and over are supposed to be checked for prostate cancer (requirement). If it is seen in a record that the procedure has not been done, or at least offered to be done, it may be brought to the attention of the doctor or clerical staff. With that, these reviewers must make sure that payment was made (by the patient or insurance) towards the test/lab/procedure. The same would go for mammograms for older women, well-child check for younger patients, vaccinations, pap smears and so on.

If you have Primary physical Custody does the non-custodian parent have rights to medical decision's on medical records?

It depends on whether or not the other parent has joint LEGAL custody which is different from Physical custody. If you were married to the other parent and now divorced, you'll have to go back and check out what is ordered in your final settlement paperwork to find out. If you weren't married, was there any court case which determined custody between the two of you? You can contact the Family Law Facilitator in your county (through the courthouse- family law division) to obtain more specific information for free. Call them for details on availability for consultation.

How can you prove to Social Security your disabilty if your medical records are old like from the 1960s and cannot not be located or have probably been destroyed?

The SSA will be the one that you will have to deal with to make your claim for disability and prove to the SSA that you meet the requirements for you to be able to receive the social security disability insurance payment amount.

Go to the SSA gov website and choose DISABILITY at the top of the page or use use the search box for DISABILITY

What is the address and fax number for medical records?

The address and fax number for medical records depends on where you went for care. Contact your health care provider for advice specific to getting your records.

In regard to medical records what is the policy for disclosing authorized data requested by third parties?

your medical records are private. but it depends on the 3rd parties requestiing the info for it to be made available to them. next time you visit the hospital save the medical records privacy act. almost any medical facility you go now will provide the info to you. someone just out of the blue can't just get your medical records, unless they work for some organization or companys. insurance companys , FBI, local police, doctors/ medical offices have easy access to your rec'd. from what i read, there's a giant computer that stores all medical info from individuals. to view this info u first get the authority and then all is available. if u ask me certain criminal records should also be private, u know like not so serious ones. they're available to the public, and in todays worls you'll be out of a job for the rest of your life.

If you possession or authorization of a persons medical records is it legal to post them online publicly?

Absolutely not.

Releasing private information as public is a violation of that individual's privacy. The individual would be well within their rights, and likely to succeed in, suing you, and they may potentially produce grounds for criminal charges.

Why should substance abuse programs comply with the regulations governing release of patient information?

Substance abuse programs often offer medical solutions and the person's information is private. The law that governs this is the The Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Does HIPAA regulations require that corrections be date and time stamped?

I can't find a mention of such a requirement in either the Privacy or Security rule. So I'm going to say No, not as a HIPAA requirement.

Why have Obama's medical records never been released?

Under federal law, certain records are private, and people (including presidents) are under no obligation to make them public. Many presidents have kept certain documents, including school transcripts and medical records, private; and doing so does not mean the person is hiding something bad. Mr. Obama, like most presidents, also releases a summary of his annual physical exam, so we do know what his health is and what procedures he had during his physical.

What if your clinic sent your medical records to the wrong fax?

Then I'm sure they feel real bad. Please don't be one of those people who due to one person making one mistake, feel the need to sue the entire clinic, thus jacking up their insurance rates, and forcing them to raise the prices on everyone. Not to mention forcing them to fire the person who did it.

Here's how you should decide whether to sue:

1. Has it really harmed me that some random person saw my medical records?

2. Have I lost any money due to some random person seeing my medical records?

3. Have a I ever made a mistake on the job that someone could have made a big deal of, but did not?

If you are like the rest of the human race, the answer to the first two should be "no" and the last one should be "yes".

If that is the case, don't sue!

Is it legal to destroy medical records?

Medical records are a complicated issue. Who owns them? The clinic or hospital that maintains the record, or the person about which the record is kept? Most states now say the clinic or hospital owns the actual physical record, and the person owns the information. This gives you the right to see your records and to decide who has access to them. In order to destroy the record a Judge would have to issue an order to the keeper of the record to expunge it. You would need a compelling reason as to why the record should be destroyed. It is currently not legal to have a medical record destroyed without a court order.

Can you request to have your medical records destroyed?

I have been trying for over a year and a half even to have medical records corrected. I have contacted the Office of Civil Right, HIPAA

Division, my Congressional representative and every State authority about some totally horrible medical records (53% lies and character assassination.) I have even tried to simply have them sealed, and this has also proved impossible.

What we can do: demand that Congress give us the power under the 4th Amendment of the Bill of Rights to demand the destruction of medical or other records that are not considered "vital statistics" such as birth, marriage, death, diplomas, etc. All medical records should be available for destruction at the patient's

request. It is far easier to get criminal records sealed than medical records!


In the mean time, under HIPAA,

demand that no records of yours may be released in any form to any human or machine under any circumstances without your witnessed wet signature. If the provider accepts this restriction, and they release your records without your witnessed wet signature, CONTACT HIPPA,

AND YOUR CONGRESSIONAL REPRESENTATIVE IMMEDIATELY!This happened to me, and I raised H_ _ _ about it. Now every time there is a request, I get a phone call and I at least get to know who is requesting my records, and I can deny access, or intervene or request a Motion to Quash. Most people do not realize how powerful that right it. The Motion to Quash is a court intervention which denies access to information and it is very powerful. It also allows you to keep a tab on who is looking into your private health records.


What is unfortunate is that I spend hours trying to clean up the mess that this particular health provider caused by releasing my records against their own agreement not to release my records.


Next, get together a list of every doctor, clinic or hospital that has treated you in the last 10 years, and send a certified letter to them demanding disclosure of everyone that they have sent any part of your records to. Then contact that other person/party and demand to know what was sent, and file corrections as necessary. If enough people demand this, then providers will begin to take patient privacy seriously. This is a lot of paperwork, but if you want to protect yourself, you have to do more than wish. You have to write!


Understand completely, that even if you file rebuttals, corrections or amendments to your medical records, all that the provider is required to do by law is include your writings in your file. They are supposed to - by law - forward these corrections to anyone else that they have sent your records to, but this does not necessarily happen. Further - and this is SO important - the 2nd party is not required by law to include and process those corrections. It works like this: Hospital sends records to Clinic. You demand that Hospital correct its records. Hospital puts your corrections in your file and is also supposed to send your corrections to Clinic, but Clinic is not under obligation to accept those corrections except that you also write and demand that Clinic accept the corrections, along with a copy of the corrections that you send to Hospital.


I have been going through a nightmare about this! If enough of us demand that Congress give us the right to control our own medical records, then perhaps something can happen. Right now, it seems that each provider takes his/her own medical history, and thus the right to destroy medical records seems of little concern, but there are those who want a central database of all our medical treatment. Nothing terrifies me more! Not only is this a privacy invasion beyond description but the patient does not even have the ability to get errors corrected!!!! Foolish example would be - it was my left foot that was operated on not my right foot. You cannot get that fixed in your medical records! You may only write a rebuttal. So you send a rebuttal to the hospital saying that if was your left foot that was operated on, not your right foot. The hospital is supposed to send that information onto anyone who got the original information that says your right foot was operated on. The clinic does not have to follow up with correcting your medical records that it was your left foot that was operated on, and in theory would either treat your right foot, which has no medical issues in the first place or charge your differently than a follow up over the left foot that should have been in the medical records in the first place. This is the level of risk we have right now. The only thing we have in our favor is that most of the medical professionals, seeing no stitches on the right foot, will remove the stitches from the left foot without changing their billing practices. Legally they can charge you differently.


We simple citizens are at the mercy of this! Until Congress et

al

starts treating us as adults who have the right to exercise judgment about our own medical records, we will continue to have to chase after those who simply do not care about our issues or our privacy, or the risk that tawdry medical records pose to those of us who are dealing with them.


Willie D.