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Access to Designated Record Set: Difference between revisions
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Access to Designated Record Set (view source)
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The designated record set (DRS) includes medical records and billing records about Individuals maintained by or for UNMC/ACE and any other record used by an ACE entity to make decisions about Individuals. Exact duplicates of records maintained by business associates are not considered part of the DRS. | The designated record set (DRS) includes medical records and billing records about Individuals maintained by or for UNMC/ACE and any other record used by an ACE entity to make decisions about Individuals. Exact duplicates of records maintained by business associates are not considered part of the DRS. | ||
===Individual=== | ===Individual=== | ||
The person who is the subject of the | The person who is the subject of the PHI. Personal representatives of the patient have the same rights as the Individual under HIPAA (i.e., they “step into the shoes” of the Individual). Personal representatives include the legal guardian and anyone else authorized by law to act on behalf of the Individual. Reference Nebraska Medicine Consents and Permits policy, MS14. | ||
===Protected Health Information (PHI)=== | ===Protected Health Information (PHI)=== | ||
Individually identifiable health information including demographic information, collected from an Individual, whether oral or recorded in any medium, that: | Individually identifiable health information including demographic information, collected from an Individual, whether oral or recorded in any medium, that: | ||
*is created or received by UNMC/ACE; and | *is created or received by UNMC/ACE; and | ||
*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 to an Individual and identifies the Individual or with respect to which there is a reasonable basis to believe the information can be used to identify the Individual. | *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 to an Individual and identifies the Individual or with respect to which there is a reasonable basis to believe the information can be used to identify the Individual. | ||
PHI includes genetic information, which includes information about: | PHI includes genetic information, which includes information about the following items (and excludes information about an Individual’s sex or age): | ||
*an Individual’s genetic tests; | *an Individual’s genetic tests; | ||
*the genetic tests of an Individual’s family members; or | *the genetic tests of an Individual’s family members; or | ||
*the manifestation of a disease or disorder in such Individual’s family members (i.e., family medical history). | *the manifestation of a disease or disorder in such Individual’s family members (i.e., family medical history); or | ||
PHI excludes individually identifiable health information of a person who has been deceased for more than fifty (50) years. | *any request for, or receipt of, genetic services (e.g., genetic test, genetic counseling, genetic education), or participation in clinical research which includes genetic services by the Individual or any family member of the Individual. | ||
PHI excludes: | |||
*individually identifiable health information of a person who has been deceased for more than fifty (50) years. | |||
*education records covered by the Family Educational Rights and Privacy Act (FERPA); and | |||
*employment records held by UNMC in its role as employer. | |||
===Psychotherapy Notes=== | ===Psychotherapy 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. | 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. | ||
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*UNMC Policy No. 6057, [https://wiki.unmc.edu/index.php/Use_and_Disclosure_of_Protected_Health_Information Use and Disclosure of Protected Health 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] | *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 Consents and Permits policy, MS14. | |||
*Nebraska Medicine’s One Chart | Patient (Electronic Health Record Portal) policy, IM45 | *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)] | ||