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<big>'''Access and Amendment of Designated Record Set Policy'''</big> | <big>'''Access and Amendment of Designated Record Set Policy'''</big> | ||
NOTE: This policy/procedure is provided to assist University of Nebraska Medical Center | '''NOTE:''' This policy/procedure is provided to assist University of Nebraska Medical Center Workforce, including those in the patient treatment areas of the Munroe-Meyer Institute for Genetics and Rehabilitation, and other clinical operations that use One Chart and associated applications, as applicable, comply with HIPAA regulations. Those departments and clinics which fall under the jurisdiction of Nebraska Medicine should consult those policies for guidance. The UNMC College of Dentistry maintains a separate policy.<br /> | ||
==Basis for Policy == | ==Basis for Policy == | ||
It is the policy of University of Nebraska Medical Center (UNMC) to comply with access and amendment requirements of the [https://www.cdc.gov/phlp/publications/topic/hipaa.html Health Insurance Portability and Accountability Act of 1996 (HIPAA)] and [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/hipaa-compliance-policy.pdf Executive Memorandum No. 27, HIPAA Compliance Policy]. | It is the policy of University of Nebraska Medical Center (UNMC) to comply with access and amendment requirements of the [https://www.cdc.gov/phlp/publications/topic/hipaa.html Health Insurance Portability and Accountability Act of 1996 (HIPAA)] and [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/hipaa-compliance-policy.pdf Executive Memorandum No. 27, HIPAA Compliance Policy]. | ||
==Policy == | ==Policy == | ||
UNMC shall provide Individuals access to inspect and obtain a copy of | UNMC shall provide Individuals access to inspect and obtain a copy of Protected Health Information (PHI) contained in the Designated Record Set maintained by UNMC or Nebraska Medicine, as applicable, and to request amendment to such information, in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). | ||
== Definitions == | == Definitions == | ||
===Affiliated Covered Entity (ACE)=== | ===Affiliated Covered Entity (ACE)=== | ||
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Notes recorded (in any medium) by a licensed mental health practitioner (LMHP) documenting or analyzing the contents of a conversation during a private counseling session or group, joint or family counseling session. Psychotherapy notes are kept separate from the Individual's medical record. Psychotherapy notes are sometimes referred to as "process notes." Psychotherapy notes exclude medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis and progress. Psychotherapy notes are not progress notes. | Notes recorded (in any medium) by a licensed mental health practitioner (LMHP) documenting or analyzing the contents of a conversation during a private counseling session or group, joint or family counseling session. Psychotherapy notes are kept separate from the Individual's medical record. Psychotherapy notes are sometimes referred to as "process notes." Psychotherapy notes exclude medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis and progress. Psychotherapy notes are not progress notes. | ||
==Procedures== | ==Procedures== | ||
===UNMC | ===UNMC Records in Designated Record Set=== | ||
#Legal Medical Record. The Health Information Management Department (HIM) shall manage access to and amendment of the Legal Medical Record for UNMC clinical operations using One Chart for patient care. Contents of the Legal Medical Record shall be approved by the Nebraska Medicine Clinical Governance Committee. | #Legal Medical Record. The Health Information Management Department (HIM) shall manage access to and amendment of the Legal Medical Record for UNMC clinical operations using One Chart for patient care. Contents of the Legal Medical Record shall be approved by the Nebraska Medicine Clinical Governance Committee. | ||
#Billing Records. The DRS billing record includes all of the data elements required on the [ CMS-1500 form] or [ Health Care Financing Administration claim form (HCFA)]. The contents shall be approved by the Nebraska Medicine Chief Financial Officer for UNMC clinical operations using One Chart for patient care. | #Billing Records. The DRS billing record includes all of the data elements required on the [ CMS-1500 form] or [ Health Care Financing Administration claim form (HCFA)]. The contents shall be approved by the Nebraska Medicine Chief Financial Officer for UNMC clinical operations using One Chart for patient care. | ||
#Any other record used in whole or in part by or for the ACE to make decisions about Individuals. | #Any other record used in whole or in part by or for the ACE to make decisions about Individuals. | ||
===Access to the | ===Access to the Designated Record Set=== | ||
#Individuals have the right to inspect and obtain a copy of PHI about the Individual in their DRS for as long as the PHI is maintained in the DRS, subject to the limitations in sections 13 and 14 below. | #Individuals have the right to inspect and obtain a copy of PHI about the Individual in their DRS for as long as the PHI is maintained in the DRS, subject to the limitations in sections 13 and 14 below. | ||
#If the same record that is the subject of the request is maintained in more than one DRS or at more than one location, the department need only produce the record once in response to a request for access. | #If the same record that is the subject of the request is maintained in more than one DRS or at more than one location, the department need only produce the record once in response to a request for access. | ||
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#Timeframe for Response. | #Timeframe for Response. | ||
#*If examination of the records is requested, HIM/UNMC shall make the records available for inspection within 10 days of the date HIM/UNMC received the request. | #*If examination of the records is requested, HIM/UNMC shall make the records available for inspection within 10 days of the date HIM/UNMC received the request. | ||
#*If unusual circumstances have delayed handling the request, HIM may notify the Individual in writing that an extension (not to exceed 21 days) from the original date UNMC received the complete request is necessary and shall provide the reasons the extension is necessary. The extension notice must state the date by which access or copies will be available. (See the Extension Notice provided with this policy.) | #*If unusual circumstances have delayed handling the request, HIM may notify the Individual in writing that an extension (not to exceed 21 days) from the original date UNMC received the complete request is necessary and shall provide the reasons the extension is necessary. The extension notice must state the date by which access or copies will be available. (See the [Extension Notice] provided with this policy.) | ||
#'''If copies of the records are requested, HIM/UNMC must produce the requested copies within 30 days of the date UNMC received the request. No extension of this date is permitted without the patient’s consent.''' | #'''If copies of the records are requested, HIM/UNMC must produce the requested copies within 30 days of the date UNMC received the request. No extension of this date is permitted without the patient’s consent.''' | ||
#*If PHI is maintained electronically in one or more DRS for such Individual and the Individual requests an electronic copy of their information, UNMC must provide such information to the Individual in the form and format requested by the Individual, if it is readily producible. If HIM/UNMC cannot readily produce it as requested by the Individual, then such information must be produced in a form and format as mutually agreed by the Individual and HIM/UNMC. If HIM/UNMC and the Individual cannot agree on an electronic form and format, then HIM/UNMC must provide a hard copy option to fulfill the access request. | #*If PHI is maintained electronically in one or more DRS for such Individual and the Individual requests an electronic copy of their information, UNMC must provide such information to the Individual in the form and format requested by the Individual, if it is readily producible. If HIM/UNMC cannot readily produce it as requested by the Individual, then such information must be produced in a form and format as mutually agreed by the Individual and HIM/UNMC. If HIM/UNMC and the Individual cannot agree on an electronic form and format, then HIM/UNMC must provide a hard copy option to fulfill the access request. | ||
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==Additional Information== | ==Additional Information== | ||
*Contact [mailto:privacy@nebraskamed.com Privacy Officer] | *Contact [mailto:privacy@nebraskamed.com Privacy Officer] | ||
*[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/hipaa-compliance-policy.pdf Executive Memorandum No. 27, HIPAA Compliance Policy] | *Contact [https://support.security.unmc.edu Office of Information Security] or 402-559-2545.*[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/hipaa-compliance-policy.pdf Executive Memorandum No. 27, HIPAA Compliance Policy] | ||
*UNMC Policy No. 6045, [https://wiki.unmc.edu/index.php/Privacy/Confidentiality Privacy, Confidentiality and Security of Patient and Proprietary Information] | |||
*UNMC Policy No. 6051, [https://wiki.unmc.edu/index.php/Computer_Use/Electronic_Information Computer Use/Electronic Information] | |||
*UNMC Policy No. 6057, [https://wiki.unmc.edu/index.php/Use_and_Disclosure_of_Protected_Health_Information Use and Disclosure of Protected Health Information] | |||
*Procedure for UNMC Policies No. 6051 and 6057, [https://info.unmc.edu/its-security/policies/procedures/electronic-comm-phi.html Electronic Communication of Protected Health Information] | |||
*Nebraska Medicine’s One Chart | Patient (Electronic Health Record Portal) policy, IM45 | |||
*[https://www.cdc.gov/phlp/publications/topic/hipaa.html Health Insurance Portability and Accountability Act of 1996 (HIPAA)] | *[https://www.cdc.gov/phlp/publications/topic/hipaa.html Health Insurance Portability and Accountability Act of 1996 (HIPAA)] | ||
Privacy Act, 5 U.S.C. § 552(a) | *[https://www.justice.gov/opcl/overview-privacy-act-1974-2020-edition Privacy Act, 5 U.S.C. § 552(a) | ||
Clinical Laboratory Improvements Amendments of 1988, 42 U.S.C. § 263a | *[https://www.govinfo.gov/app/details/USCODE-2020-title42/USCODE-2020-title42-chap6A-subchapII-partF-subpart2-sec263a Clinical Laboratory Improvements Amendments of 1988, 42 U.S.C. § 263a] | ||
*[https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-493Clinical Laboratory Improvements Amendments of 1988, 42 C.F.R. § 493] | |||
*[Patient Access Request form] | *[Patient Access Request form] | ||
*[Authorization for Release of Information] | *[Authorization for Release of Information] | ||
*[Complaint form referenced in #12, called attachment 1 - we'll want to use actual form name] | |||
*[Extension Notice] | |||
This page maintained and updated by [mailto:dpanowic@unmc.edu dkp]. | This page maintained and updated by [mailto:dpanowic@unmc.edu dkp]. | ||