Access to Designated Record Set

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Policy No.: 6059
Effective Date: 03/17/03
Revised Date: 08/19/22 Draft
Reviewed Date:

Access and Amendment of Designated Record Set Policy

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.

Basis for Policy

It is the policy of University of Nebraska Medical Center (UNMC) to comply with access and amendment requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and Executive Memorandum No. 27, HIPAA Compliance Policy.

Policy

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

Affiliated Covered Entity (ACE)

Legally separate covered entities that designate themselves as a single covered entity for the purpose of HIPAA Compliance. Current ACE members are: The Nebraska Medical Center, UNMC Physicians, UNMC, University Dental Associates, Bellevue Medical Center and Nebraska Pediatric Practice, Inc. ACE membership may change from time to time. The Notice of Privacy Practices lists current ACE members. Access and amendment rights apply to designated record sets throughout the ACE.

Designated Record Set (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

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)

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
• 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 the following items (and excludes information about an Individual’s sex or age):

• an Individual’s genetic tests;
• 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); or
• 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

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

UNMC Records in Designated Record Set

1. 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.
2. 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.
3. Any other record used in whole or in part by or for the covered entity to make decisions about Individuals.

Access to the Designated Record Set

1. 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.
2. 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.
3. Initiating a Request. Individuals shall complete a [Patient Access Request form] to inspect and/or obtain a copy of the DRS, and submit it to HIM. HIM is responsible for the processing of all such requests. If the Individual completes an [Authorization for Release of Information] and the recipient is the Individual or a third party designated by the Individual, this will be treated as a request for access.
4. Review for Completeness. When a Patient Access Request or Authorization for Release of Information form is received, HIM shall review the form for completion. If any information is incomplete that is necessary for an access request (NOTE: some information on the Authorization for Release of Information is not necessary for a request for access), HIM will notify the Individual that they cannot process the incomplete request. HIM should document on the form the attempts to contact the Individual.
5. Timeframe for Response.
   • If examination of the records is requested, HIM/UNMC shall make the records available for inspection within ten (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.)
6. 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 the Individual directs HIM/UNMC to transmit an electronic copy to a third party, HIM/UNMC will comply with such request, provided that the Individual's directions are clear, conspicuous, and specific, and the direction is in writing. If the Individual's directions are not clear, conspicuous, and specific, HIM/UNMC will attempt to contact the Individual to clarify their request. HIM/UNMC may provide the Individual with a summary (abstract) of the PHI requested, in lieu of providing access to PHI or may provide an explanation of the PHI to which access has been provided, if the Individual agrees to the summary or explanation in advance, including any fees imposed for such summary or explanation (see Fees, below in Section 7).
7. Fees. If an Individual requests a copy of the PHI, HIM/UNMC may impose cost-based fees, not to exceed $0.50 (50 cents) per page. The basis for calculating such fee must be documented and may include staff time to create and copy the electronic file, such as compiling, extracting, scanning and writing the information to portable media. The cost-based fee may also include the cost of the agreed-upon electronic media, such as a USB drive, or creating a paper copy. If a summary or explanation is requested in advance by the patient and the patient has agreed to the fee for such request, HIM/UNMC may charge a pre-determined fee for preparation of such summary or explanation. Reference the fee schedule attached to HIM department policy, Responding to Requests for Clinical Information: External Requestors, ROI 050.
8. Production of Records. If access to the requested information is granted in whole or in part, HIM will arrange for a convenient time and place for the patient to inspect the records or obtain a copy.
   • Inspection will generally be during normal business hours of HIM, unless special circumstances are present. Consult the Privacy Officer if the patient requests to inspect the records or obtain a copy before or after normal business hours.
9. At the patient’s request, HIM will mail a copy of the records in the format requested to the patient at the address designated on the request form. If requested by the patient, HIM will email a copy of the records to the patient. If the patient requests the records be sent by unsecured email, HIM will confirm that the patient understands the information could be intercepted before complying with the request.
10. If the patient requests in advance an explanation or summary of the information and agrees to pay the fee for preparing the summary, HIM shall prepare the summary and provide it to the patient.
11. The patient will be notified when the records are available for inspection or that a copy is available for pick-up or mailing/e-mailing. The total cost to the Individual for producing and mailing/e-mailing a copy should be included. Payment for copying/mailing/e-mailing the requested records will be collected prior to the time the records are released. Patients generally have access to their own medical information during and after treatment via the One Chart | PATIENT portal. The One Chart | PATIENT portal is a secure online application that allows patients to view portions of their medical and billing record. Patients may give others proxy access to their portal account. Parents may obtain limited proxy access to the records of their children. Reference Nebraska Medicine’s One Chart | Patient (Electronic Health Record Portal) policy, IM45, for current information on eligibility for patient and proxy access.
12. Denials of Access. HIM should review the request to determine if one or more of the following grounds for denying access exists as to all or part of the requested records. Access may be denied, in coordination with HIM and the Privacy Office, for reasons listed under Sections 13 and 14 below. The patient must be provided with a written denial, including the basis for denial; a statement of their review rights under section 14 below if applicable; and a description of how the Individual may file a complaint to HIM/UNMC, along with name, title and telephone number, or to the Secretary Health and Human Services (see form at Attachment 1). If UNMC does not maintain the PHI that is the subject of the Individual's request for access, and knows where the requested information is maintained, UNMC will inform the Individual where to direct the request for access.
13. Unreviewable Grounds for Denial of Access. HIM, in coordination with the Privacy Office, may deny the Individual the right to access his/her DRS for reasons listed below without providing the Individual with an opportunity for review.
    • The information requested is not maintained by UNMC or ACE. If HIM knows where such information is maintained, the location should be noted in our response to the Individual;
    • The information requested is subject to the Privacy Act, 5 U.S.C. § 552(a);
    • The request is for access to Psychotherapy notes;
    • The requested information was compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding;
    • The information requested is maintained by a clinical laboratory subject to the Clinical Laboratory Improvements Amendments of 1988, 42 U.S.C. § 263a, and access by the Individual is prohibited by law;
    • The information requested are records of a research laboratory exempt from the Clinical Laboratory Improvements Amendments of 1988, 42 C.F.R. § 493;
    • The request is for information regarding on-going research where treatment is being rendered as part of such research, provided that the Individual has agreed to the denial of access when consenting to participate in the research, and the health care provider providing treatment has informed the Individual that the right of access will be reinstated upon completion of the research;
    • The information was obtained from someone other than a health care provider under a promise of confidentiality, and the access requested would be reasonably likely to reveal the source of the information; or
    • The request is from an inmate of a correctional facility and treatment was provided to the inmate under the direction of the correctional facility. The correctional facility must notify HIM/UNMC that obtaining a copy would jeopardize the health, safety, security, custody or rehabilitation of the Individual. HIM may provide copies to the correctional facility to arrange for inspection by the inmate.
14. Reviewable Grounds for Denial of Access. Departments, in coordination with HIM and the Privacy Office, may also deny the Individual access to the DRS for the following reasons, but must provide the Individual with an opportunity for secondary review:
    • An attending physician has determined, in the exercise of professional judgment, that the access requested is reasonably likely to endanger the life or physical safety of the Individual or another person;
    • The PHI makes reference to another person (unless such other person is a health care provider) and a licensed health care professional has determined, in the exercise of professional judgment, that the access requested is reasonably likely to cause substantial harm to such other person; or
    • The request for access is made by the Individual's personal representative and a licensed health care professional has determined, in the exercise of professional judgment, that the provision of access to such personal representative is reasonably likely to cause substantial harm to the Individual or another person.
15. Review of Denial. Upon request, the Individual has the right to have denials listed under section 14 above reviewed by another licensed health care professional who did not participate in the original denial. The Nebraska Medicine Chief Medical Officer is the designated reviewing official. If the Chief Medical Officer is not available, the Nebraska Medicine Clinical Governance Committee chair shall review the request. Requests shall be reviewed as soon as possible, but no later than thirty (30) days from submission of the request. HIM must promptly provide written notice to the Individual of the determination of the designated reviewing official, which is final. If access to any information is denied, HIM/UNMC will, to the extent possible, provide access to any remaining information after the information to which access was denied has been removed or redacted.

Amendment of Designated Record

Individuals have the right to request amendment of PHI about them which is maintained by UNMC or its business associates in the DRS. HIM/UNMC shall receive and process such requests according to the following procedures:

1. Individuals may submit a written Request for [Correction/Amendment of Medical/Billing Information form] to HIM, providing rationale for the requested amendment.
   • HIM will review the form for completion. If any information is incomplete, HIM will notify the Individual that UNMC cannot process the incomplete request. HIM will document on the Request form the attempts to contact the Individual.
   • HIM shall contact the author of clinical PHI to approve/deny the requested amendment. If the author is a medical student, resident or allied health professional with a supervising physician, the supervising physician shall approve/deny the requested amendment. If the request involves billing or payment information, Patient Financial Services should be consulted.
2. Approval. If the amendment is accepted in whole or in part, HIM must identify the records containing the information. Such records will be amended by lining through the information and appending the amendment, or by providing a link to the location of the amendment. The original information should never be erased or removed from the record.
3. Notifying Third Parties.
   • UNMC will make reasonable attempts to notify those persons/entities who are identified by the patient of the amendment.
   • HIM and UNMC will identify other persons/entities (including business associates of UNMC) that HIM/UNMC knows to be in possession of the information and who may have relied on the information or could foreseeably rely on the information to the detriment of the patient. HIM/UNMC will obtain the patient’s permission to notify parties identified by HIM/UNMC as described above and will make reasonable attempts to notify those third parties of the amendment.
4. Denial. Requests for amendment may be denied if one of the following grounds for denial exists:
   • The information or record was not created by UNMC. Note: Continue to process the request if the Individual provides credible information that the creator of the information or record is not available to act on a request for amendment.
   • The disputed information or record is not part of a designated record set.
   • The disputed information is not subject to access by the Individual. (Refer to the section on Requests for Access above.)
   • The information is accurate and complete as written. Note: If the requested amendment relates to clinical information, HIM must consult with the licensed health care professional who created the information or an appropriate alternate if such person is not available to determine whether the information is accurate and complete.
5. Notifying the Individual of the Denial. If one of the above grounds exists, HIM will notify the Individual that UNMC has denied the request for amendment, using the Notice of Approved/Denied Request for Amendment form. The notice should inform the Individual of their rights regarding the denied request for amendment.
6. Rights of Individual if the Request is Denied. UNMC must permit the Individual to submit a written statement of disagreement to UNMC. The statement of disagreement must be in writing and limited to one page.
   • If a statement of disagreement is submitted, all future disclosures of the disputed information must include the following: Request for Amendment; Denial Notice; Statement of Disagreement; and UNMC’s Rebuttal (if any).
   • If a statement of disagreement is not submitted, the Individual has the right to request that UNMC attach the Request for Amendment and Denial Notice to any future disclosures of the disputed information. Attach such Request only upon request of the Individual.
7. Rebuttal by UNMC. UNMC will generally not issue a rebuttal statement unless special circumstances warrant. The author of the information should be consulted if HIM believes that a particular statement of disagreement submitted by a patient warrants a rebuttal by UNMC.
8. Timeframe for Response. HIM shall respond back to the requestor in writing within 60 days of the date UNMC received the amendment request. If HIM determines that UNMC is unable to respond to the request within sixty (60) days, HIM must notify the Individual in writing that one 30-day extension is necessary to respond to the request and shall provide the reasons the extension is necessary. The extension notice must state the date by which action on the request will be taken.
9. Recordkeeping. The request for amendment, denial of the request, and statement of disagreement/rebuttal statement (if any) must be placed (append or otherwise linked in the electronic record) in the DRS and provided to the Individual as a part of a request for access.

Additional Information

• Contact Privacy Officer
• Contact Office of Information Security or 402-559-2545
• Executive Memorandum No. 27, HIPAA Compliance Policy
• UNMC Policy No. 6045, Privacy, Confidentiality and Security of Patient and Proprietary Information
• UNMC Policy No. 6051, Computer Use/Electronic Information
• UNMC Policy No. 6057, Use and Disclosure of Protected Health Information
• Procedure for UNMC Policies No. 6051 and 6057, 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
• Health Insurance Portability and Accountability Act of 1996 (HIPAA)
• Privacy Act, 5 U.S.C. § 552(a)
• Clinical Laboratory Improvements Amendments of 1988, 42 U.S.C. § 263a
• Clinical Laboratory Improvements Amendments of 1988, 42 C.F.R. § 493
• [Patient Access Request form]
• [Authorization for Release of Information]
• [Complaint form referenced in #12, called attachment 1 - we'll want to use actual form name]
• [Extension Notice]

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