BUL4602 Fall-2011 Lecture 8, Reading 1

BUL4602 Fall-2011 Lecture 8, Reading 1 - MEDICAL RECORDS...

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MEDICAL RECORDS RELEVANT LAWS [Instructor’s comments bracketed] [ . . . deleted words, * * * deleted sentences] Page 1 of 25 |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||| WHAT IS A MEDICAL RECORD? HIPAA Privacy/Security Rule says: Chapter 45 Code of Federal Regulations § 160.103 Definitions * * * Health information means any information, whether oral or recorded in any form or medium, that: (1) Is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, 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 . . . . * * * Individually identifiable health information is . . . health information . . . created or received by a health care provider, health plan, employer, or health care clearinghouse; and . . . identifies the individual; or . . . can be used to identify the individual. [Note: public health authority is excluded from this definition ] * * * Protected Health information means individually identifiable health information . . . that is: (i) Transmitted by electronic media; (ii) Maintained in electronic media; or (iii) Transmitted or maintained in any other form or medium. (2) Protected health information excludes individually identifiable health information in: (i) Education records covered by the Family Educational Rights and Privacy Act, as amended, 20 U.S.C. 1232g; (ii) Records described at 20 U.S.C. 1232g(a)(4)(B)(iv); and (iii) Employment records held by a covered entity in its role as employer. FLORIDA LAW SAYS: Section 395.3015, Florida Statutes: [A] system of problem-oriented medical records for its patients, which system shall include the following elements: basic client data collection; a listing of the patient's problems; the initial plan with diagnostic and therapeutic orders as appropriate for each problem identified; and progress notes, including a discharge summary.
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MEDICAL RECORDS RELEVANT LAWS [Instructor’s comments bracketed] [ . . . deleted words, * * * deleted sentences] Page 2 of 25 Florida Administrative Code Rule 64B8-9.003 [Florida Board of Medicine], Standards for Adequacy of Medical Records. (1) Medical records are maintained for the following purposes: (a) To serve as a basis for planning patient care and for continuity in the evaluation of the patient’s condition and treatment. (b) To furnish documentary evidence of the course of the patient’s medical evaluation, treatment, and change in condition. (c) To document communication between the practitioner responsible for the patient and
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BUL4602 Fall-2011 Lecture 8, Reading 1 - MEDICAL RECORDS...

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