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: '''09/20/22 Draft'''<br />
Revised Date: '''10/28/22 Draft'''<br />
Reviewed Date:<br />
Reviewed Date:<br />


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==Definitions==
==Definitions==
===Affiliated Covered Entity (ACE)===
===Affiliated Covered Entity (ACE)===
Legally separate covered entities that are affiliated and 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. Access and amendment rights apply to designated record sets throughout the 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.  


===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 an ACE entity to make decisions about Individuals. Exact duplicates of records maintained by business associates are not considered part of the DRS.
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); or
*the manifestation of a disease or disorder in such Individual’s family members (i.e., family medical history).
*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:
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 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 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]