Access to Designated Record Set: Difference between revisions

It is the policy of University of Nebraska Medical Center (UNMC) to comply with access and amendment requirements of the [https://www.cdc.gov/phlp/publications/topic/hipaa.html Health Insurance Portability and Accountability Act of 1996 (HIPAA)] and [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/hipaa-compliance-policy.pdf 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.

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:

*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. 

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.

===UNMC Records in Designated Record Set===

#'''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.   

#*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.)

#'''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).

#'''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.