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Access to Designated Record Set: Difference between revisions
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Policy No.: '''6059'''<br /> | Policy No.: '''6059'''<br /> | ||
Effective Date: '''03/17/03'''<br /> | Effective Date: '''03/17/03'''<br /> | ||
Revised Date: ''' | Revised Date: '''06/06/24'''<br /> | ||
Reviewed Date:<br /> | Reviewed Date: '''06/06/24'''<br /> | ||
<big>'''Access and Amendment of Designated Record Set Policy'''</big> | <big>'''Access and Amendment of Designated Record Set Policy'''</big> | ||
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Nebraska Medicine/UNMC designates the following records as its DRS: | Nebraska Medicine/UNMC designates the following records as its DRS: | ||
#'''Legal Medical Record'''. The Health Information Management Department (HIM) shall manage access to and amendment of the Legal Medical Record. Contents of the Legal Medical Record shall be approved by the Clinical Governance Committee. | #'''Legal Medical Record'''. The Health Information Management Department (HIM) shall manage access to and amendment of the Legal Medical Record. Contents of the Legal Medical Record shall be approved by the Clinical Governance Committee. | ||
#'''Billing Records'''. The DRS billing record includes all of the data elements required on the [ CMS-1500 form] | #'''Billing Records'''. The DRS billing record includes all of the data elements required on the [ CMS-1500 form] https://cms-1500-claim-form.com or [ [https://cms-1500-claim-form.comHealth Care Financing Administration claim form 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 covered entity to make decisions about Individuals. | #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=== | ===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. | ||
#'''Initiating a Request'''. Individuals shall complete a | #'''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. An Individual can request '''Patient Access at [mailto:Privacy@NebraskaMed.com Privacy@NebraskaMed.com]''' and the recipient is the Individual or a third party designated by the Individual, this will be treated as a request for access. | ||
#'''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. | #'''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. | ||
#'''Timeframe for Response.''' | #'''Timeframe for Response.''' | ||
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#If the Individual 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 Individual. | #If the Individual 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 Individual. | ||
#The Individual 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. Individuals 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 Individuals to view portions of their medical and billing record. Individuals 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. | #The Individual 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. Individuals 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 Individuals to view portions of their medical and billing record. Individuals 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. | ||
#'''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 Individual must be provided with a written denial, including the basis for denial; a statement of their review rights under n below if applicable; and a description of how the Individual may file a complaint to Nebraska Medicine/UNMC, along with name, title, and telephone number, or to the Secretary Health and Human Services ''' | #'''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 Individual must be provided with a written denial, including the basis for denial; a statement of their review rights under n below if applicable; and a description of how the Individual may file a complaint to Nebraska Medicine/UNMC, along with name, title, and telephone number, or to the Secretary Health and Human Services '''Denial of Access to Medical Record/Billing Record is created by HIM on an as-needed basis. If Nebraska Medicine/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, Nebraska Medicine/UNMC will inform the Individual where to direct the request for access.''' | ||
#'''Unreviewable Grounds for Denial of Access'''. HIM, in coordination with the Privacy Office, may deny the Individual the right to access their DRS for reasons listed below without providing the Individual with an opportunity for review. | #'''Unreviewable Grounds for Denial of Access'''. HIM, in coordination with the Privacy Office, may deny the Individual the right to access their DRS for reasons listed below without providing the Individual with an opportunity for review. | ||
#*The information requested is not maintained by Nebraska Medicine/UNMC. If HIM knows where such information is maintained, the location should be noted in our response to the Individual; | #*The information requested is not maintained by Nebraska Medicine/UNMC. If HIM knows where such information is maintained, the location should be noted in our response to the Individual; | ||
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===Amendment of Designated Record=== | ===Amendment of Designated Record=== | ||
Individuals have the right to request amendment of PHI about them which is maintained by Nebraska Medicine/UNMC or its business associates in the DRS. Nebraska Medicine/UNMC shall receive and process such requests according to the following procedures: | Individuals have the right to request amendment of PHI about them which is maintained by Nebraska Medicine/UNMC or its business associates in the DRS. Nebraska Medicine/UNMC shall receive and process such requests according to the following procedures: | ||
#Individuals may submit a written Request for [Correction/Amendment of Medical/Billing Information form] | #Individuals may submit a written Request for [mailto:Privacy@NebraskaMed.com 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 Nebraska Medicine/UNMC cannot process the incomplete request. HIM will document on the Request form the attempts to contact the Individual. | #*HIM will review the form for completion. If any information is incomplete, HIM will notify the Individual that Nebraska Medicine/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. | #*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. | ||
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==Definitions== | ==Definitions== | ||
===Affiliated Covered Entity (ACE)=== | ===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. d/b/a Children’s Specialty Physicians. ACE membership may change from time to time. The Notice of Privacy Practices lists current ACE members. | 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. d/b/a Children’s Specialty Physicians. ACE membership may change from time to time. The Notice of Privacy Practices lists current ACE members. | ||
===Designated Record Set (DRS)=== | ===Designated Record Set (DRS)=== | ||
Includes medical records and billing records about Individuals maintained by or for UNMC/ACE and any other record used by | Includes medical records and billing records about Individuals maintained by or for UNMC/ACE and any other record used by the ACE to make decisions about Individuals. | ||
===Individual=== | ===Individual=== | ||
The person who is the subject of the PHI. Personal representatives of the Individual 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. (See Nebraska Medicine Consents and Permits policy, MS14.) | The person who is the subject of the PHI. Personal representatives of the Individual 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. (See Nebraska Medicine Consents and Permits policy, MS14.) | ||
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*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). | ||
PHI excludes: | PHI excludes: | ||
*individually identifiable health information of a person who has been deceased for more than fifty (50) years. | *individually identifiable health information of a person who has been deceased for more than fifty (50) years. | ||
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*employment records held by UNMC in its role as employer. | *employment records held by UNMC in its role as employer. | ||
===Psychotherapy Notes=== | ===Psychotherapy Notes=== | ||
Notes recorded (in any medium) by a | Notes recorded (in any medium) by a mental health provider including psychiatrists, psychologists and other mental health professionals 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 rest of the individual’s medical record. 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 to date. Psychotherapy notes are not progress notes and are created at the discretion of the mental health care provider. (HIPAA: 45 CFR §164.501) | ||
==Additional Information== | ==Additional Information== | ||
*Contact [mailto:privacy@nebraskamed.com Privacy Officer] | *Contact [mailto:privacy@nebraskamed.com Privacy Officer] | ||
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*[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.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-493 Clinical Laboratory Improvements Amendments of 1988, 42 C.F.R. § 493] | *[https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-493 Clinical Laboratory Improvements Amendments of 1988, 42 C.F.R. § 493] | ||
*[ CMS-1500 form] | *[https://cms-1500-claim-form.com CMS-1500 form] | ||
*[ Health Care Financing Administration claim form | *[https://cms-1500-claim-form.com Health Care Financing Administration claim form] | ||
* | *Patient Access Request form | ||
* | *Authorization for Release of Information Form, CON MR 0074 | ||
* | *Denial of Access to Medical Record/Billing Record | ||
*[ Correction/Amendment of Medical/Billing Information form] | *[mailto:Privacy@unmc.edu Correction/Amendment of Medical/Billing Information form] | ||
*[ Notice of Approved/Denied Request for Amendment form ] | *[mailto:Privacy@NebraskaMed.com Notice of Approved/Denied Request for Amendment form] | ||
This page maintained and updated by [mailto: | This page maintained and updated by [mailto:mhurlocker@unmc.edu mh]. | ||