Medical Records

A person's (patient) medical record is the history of what medical illnesses and the medicine prescribed the person received to date.

Inmate medical records are typically retained for a specified period, often ranging from five to seven years after the inmate's release or discharge. However, policies may vary by jurisdiction and facility, so it's essential to consult local regulations or institutional guidelines for the exact duration. Some facilities may retain records longer if required for ongoing legal or medical reasons.

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The American Health Information Management Association (AHIMA) provides accrediting standards for medical records. AHIMA sets guidelines for the management and quality of health information, ensuring that medical records are accurate, secure, and accessible. Additionally, the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) also plays a role in accrediting educational programs related to health information management.

Protected health information (PHI) is any information that can be linked to an individual's health condition, provision of healthcare, or payment of healthcare. It includes details such as names, dates of birth, medical record numbers, and any other identifying information. If information can identify an individual and is related to their health, it is likely PHI.

biometric data

credit card number

social security number

alien registration number

For the lifetime of the person.

Under the Occupational Safety and Health Act (OSHAct), employees have the right to access their medical records maintained by their employer. This includes the right to review and obtain copies of records related to their health and any workplace exposures to hazardous substances. Employers must provide access to these records within a reasonable timeframe and cannot deny access without valid reasons. Employees can also request corrections to their medical records if they believe there are inaccuracies.

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Headings in a medical record are structured titles or labels that categorize different sections of patient information, facilitating easy navigation and comprehension. Common headings include "Patient History," "Diagnosis," "Treatment Plan," and "Medications." These headings help healthcare providers quickly locate relevant information, ensuring efficient communication and continuity of care. Properly organized headings enhance the overall quality and usability of medical records.

Medical records is the collection of information about the health of the patient. The medical history(allergy,symptoms),past surgery,medication,prescription,vaccination and immunization are maintained in the medical record.the information might be written or stored in electronic format.Documentation of the medical reports and health information.

Medical records are confidential. They should only be released after the patient has signed a release form.

Police keep records of suicide attempts because it is considered to be a criminal matter and doing so helps the police keep track of individuals in danger.

Patient's Bill of Rights is the right for medical treatment and intervention. It is the HIPAA Privacy Rule that protects the privacy of individual health information. The HIPAA Security Rule then, sets the national standards for the security of electronic protected health information while the HIPAA Breach Notification Rule requires covered medical and allied health professional clinic and offices a notification following a breach of unsecured protected health information. There are also provisions for confidentiality within the Patient Safety Rule. This protects identifiable information being used to analyze patient safety events and improve patient safety.

Flow sheets and medication records are tools used in healthcare to track patient information and treatment. Flow sheets provide a structured format for clinicians to document vital signs, lab results, and other clinical data over time, allowing for easy monitoring of patient progress. Medication records, on the other hand, detail a patient's prescribed medications, dosages, and administration schedules, ensuring accurate medication management and adherence. Together, these records enhance communication among healthcare providers and improve patient care.

privileged communication

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who was the first federal legislation to deal thoroughly and explicitly with the privacy of medical records.

Your medical history isn't carefully organized in one place; it resides with every caregiver and payer you've ever had. Start with finding at least one covered entity (CE) for each period of your life. Identifying them is the hard part.

If your current caregiver needs or wants this information, tell them to ask for it -- they'll know how (usually). If you need the info yourself, do this:

Once you've found a CE, ask them for your Designated Record Set (DSR). Under law, they have to give this to you, except in very unusual circumstances. They are also legally entitled to ask you to frame this request in writing, and most if not all will have a form you can use for this purpose.

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