Designated Record Set Health Record The health information described below may be maintained in any medium (paper, electronic, digital, etc)

Transcription

1 Designated Record Set Health Record The health information described below may be maintained in any medium (paper, electronic, digital, etc) DEFINITION Designated Record Set A group of records (recorded in any medium) containing protected health information that are maintained by or for OHSU and includes the health records and billing records about individuals that are used in whole, or in part, by OHSU to make decisions about individuals. Individually Identifiable Health Information any health information that is created or received by OHSU, including demographic information that identifies the individual, or for which there is a reasonable basis to believe the information can be used to identify an individual, and that relates to: (i) the past, present or future physical or mental health or condition of an individual; (ii) the provision of health care to the individual; or (iii) the past, present or future payment for the provision of health care to an individual. Protected Health Information (PHI) - individually identifiable health information that is transmitted or maintained in any form, whether oral, electronic or paper (Ref: 45 CFR ) Designated Record Set Medical Record Anesthesia Records Authorizations, Informed Consents, and Terms & Conditions Autopsy Report Care Plans Clinical Communications Consultation Reports Record of Anesthesia documentation Documents signed by the patient or legal representative authorizing a specific treatment, procedure, or action Documentation of a patient s plan for treatment and other communications containing patient-provider or provider-to provider communication Reports from specialist, therapist, or other supporting health care professionals Anesthesiologist records and checklists Terms & Conditions, Informed consents, Authorizations for use and disclosure, Informed Consents for clinical/interventional research (Studies involving treatment and payment activities) Interdisciplinary plan of care Physician consult report, physical therapy evaluation form, dietitian evaluation form, etc Last Revised 3/09/2003 Page 1 of 5

2 Diagnosis Diagnostic Test Results & Interpretations Discharge & Follow-Up Instructions Discharge Summary Emergency Department Record Health Care Decision Instructions Identification and Registration Information Immunization Records Medical History & Physical Examination Reports Medication Records Nursing Assessment Office Visits Clinic notes Operation & Procedure Supporting Documentation Operative & Procedure Reports Other Health Care Professional Documentation Patient Education Records Diagnosis information used primarily by health care professionals, or the physician s description of the medical condition being treated. Results or interpretation of the test Information provided to patient regarding their follow-up care Summary of hospitalization Patient healthcare records documented during an emergency visit Patient s instructions for health care decisions Patient demographic and insurance information Initial assessments or history and physical documents or forms Documentation about administration of medicines to a patient Documentation on standard forms or free text Patient health care records documented for a specific type of office visit Record by nursing or other health care professionals about a specific operation or procedure Summary by the physician of the operation or procedure Documentation or assessments done by health care support personnel Records about the specific education provided to a patient Problem list, discharge summary, history & physical exam, etc. Clinical laboratory reports, radiology reports, pathology findings, EKG, special study reports (EMG, audiology, stress tests, etc) Discharge instruction form specific to a patient s treatment. Emergency room report and other documents related to an ER visit Advance Directives, Living will, Making Health Care Decisions Booklet, Physician Orders for Life-Sustaining Treatment (POLST) Pre-admission, admission, or other registration documents or forms Dictated report, short stay report, handwritten report Various types of medication records and forms Nursing acuity assessments, nursing care documentation Documents created during a specific office &/or clinic visit Surgical nursing records, flowsheets, pre- and post operation or procedure documents Dictated/written operative report Discharge planning orders, various flowsheets, social worker assessment, and other specialty forms Nutrition education, interdisciplinary teaching records, etc Last Revised 3/09/2003 Page 2 of 5

3 Photographs/films Physician Orders Progress Notes Received from other health care entities &/or patient (outside records) Rehabilitation Records Treatment Records Photographs obtained during a patient encounter. Radiology films Documentation by the physician ordering services from ancillary services Documentation of a patient s response to care or treatment Information that may be received from other facilities, providers or patients that are used for medical decision making Patient healthcare records documented for services from rehabilitation Records documenting the specific events from a patient s treatment session Photographs, X-ray films Standard inpatient orders or orders recorded in the ambulatory record. Patient progress notes and forms Various documents received from other outside sources used for medical decision making Physical, occupations, speech or other rehabilitation evaluation or treatment records. Any documentation for treatment of patient not included in other categories Designated Record Set Billing (Medical) Account Communication (with the patient and insurance companies) Appeal Letters to Insurance Company Basic Account Information Collection Documents Detailed Account Information Insurance Claim Forms Remittance Advise Other Billing Documents Other Financial Documents Notes recorded about a patient s account Summary information about a patient s account balance,, and demographics Documents used for or sent to a collection agency for Detail information about a Documents submitted to insurance companies for billing decisions financial decisions Log of telephone or other correspondence on a patient s account with the patient or insurance companies Summary statements, financial assistance application Itemized statements Standard insurance claim forms, UB92 and 1500 Clinic fee tickets, certificate of medical necessity, prescriptions Statement of financial responsibility, Advance Billing Notice Last Revised 3/09/2003 Page 3 of 5

4 Designated Record Set Dental Records* *excludes Oral and Maxillofacial Surgery and Clinical Research records for clinics at Hatfield Dental Chart Predoctoral all clinical disciplines, Graduate Endodontics, Graduate Periodontics, Predoctoral Oral Surgery, Urgent Care Records of patients receiving orthodontic care Records of patients treated in the Axium electronic records Orthodontic Record Axium electronic records Faculty Dental Practice Record Faculty Dental Practice Daisey electronic records Russell Street Clinic Record Records of patients treated at Russell Street Clinic Daisey or Epoch electronic records Oral Pathology Records Records of patient biopsies Biopsy submissions, reports, histological slides Digital Images and Analog Digital and analog images of Images patients and patient care Dental Labs Records of laboratory prescriptions for dental restorations and appliances Graduate endodontic digital radiographs, all clinics photographs of patients and clinical scenarios Rx for fixed and removable prosthetics, orthdontic applicances, restorations, etc. Example forms from the main dental chart are listed below (this is not a complete listing). Example form names: Anxious Patient Packet Contents Re-Evaluation / Recall Exam Dental - Medical Findings Continuing Care Program Language Interpreter Request Medical Consultation Request Worksheet Fixed Prosthodontics Clinical Evaluation Fixed Prosthodontics Clinical Progress Sheet Fixed Prosthodontic Treatment Worksheet Nitrous Oxide Sedation Record N 2 O/O 2 Utilization Record Oral and Maxillofacial Surgery Referral Orthodontic Consultation Financial Agreement for Patients With Dental Insurance Dental Claim Form Oral Health / Prevention Sticker Last Revised 3/09/2003 Page 4 of 5

5 Referral to Graduate Periodontology Plaque Index Form Student Communication Tobacco Intervention Outcomes Wax Trial Insertion Appt. Checklist Initial Interview for Immediate Denture Initial Interview for Edentulous Patient Removable Partial Denture Treatment Plan Your Guide to Immediate Dentures Designated Record Set Billing (Dental) Account Communication (with the patient and insurance companies) Basic Account Information Collection Documents Detailed Account Information Insurance Claim Forms Other Billing Documents Other Financial Documents Notes recorded about a patient s account Summary information about a Documents used for or sent to a collection agency for Detail information about a Documents submitted to insurance companies for billing decisions financial decisions Electronic notes in Axium Summary statements, patient agreement forms, insurance information, OHP waivers (electronic and paper) Documents sent to collection agencies Itemized statements Standard insurance claim forms Clinic fee tickets, description of dental/medical necessity, prescriptions Statement of financial responsibility, Advance Billing Notice Last Revised 3/09/2003 Page 5 of 5