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Access to Designated Record Set: Difference between revisions
Access to Designated Record Set (view source)
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, August 15, 2023→Affiliated Covered Entity (ACE)
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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: '''10/28/22 Draft'''<br /> | ||
Reviewed Date:<br /> | Reviewed Date:<br /> | ||
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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] 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] '''( form name and URL please)''' or [ Health Care Financing Administration claim form (HCFA)] '''(URL please)'''. 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 | #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 [Patient Access Request form (not yet approved)] 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 Form, CON MR 0074] please advise (URL)'''and the recipient is the Individual or a third party designated by the Individual, this will be treated as a request for access. | #'''Initiating a Request'''. Individuals shall complete a [Patient Access Request form (not yet approved)] 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 Form, CON MR 0074] please advise (URL)'''and the recipient is the Individual or a third party designated by the Individual, this will be treated as a request for access. | ||
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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] '''( form name and URL please)''' | |||
*[ Health Care Financing Administration claim form (HCFA)] '''(URL please)''' | |||
*[Patient Access Request form] (not yet approved) | *[Patient Access Request form] (not yet approved) | ||
*[Authorization for Release of Information Form, CON MR 0074] | *[Authorization for Release of Information Form, CON MR 0074] | ||
*[ Denial of Access to Medical Record/Billing Record] | *[ Denial of Access to Medical Record/Billing Record] | ||
*[ Correction/Amendment of Medical/Billing Information form] '''(URL please)''' it would help if this was a separate URL from the denial of access to medical record when it was saved on your web site | *[ Correction/Amendment of Medical/Billing Information form] '''(URL please)''' it would help if this was a separate URL from the denial of access to medical record when it was saved on your web site | ||
*[ Notice of Approved/Denied Request for Amendment form ' | *[ Notice of Approved/Denied Request for Amendment form ] '''(URL please)''' it would help if this was a separate URL from the denial of access to medical record when it was saved on your web site | ||
This page maintained and updated by [mailto:dpanowic@unmc.edu dkp]. | This page maintained and updated by [mailto:dpanowic@unmc.edu dkp]. | ||