MEDICAL  RECORDS

PRIVACY

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      A resident’s medical record is the foundation of the individual’s ongoing medical care. Putting into writing what medical diagnosis has been established for the resident, what is the recommended respond to those findings, what has been done for those identified problems, what is being done today, and what responses are planned for the future is necessary to coordinate the treatment of the resident by a variety of medical professionals along with establishing a history of that treatment and the resident’s response to care.


  


                                                       PAGE CONTENTS

                  ∆  Clinical records as history.

                  ∆  Limits to accessing medical records.

                  ∆  Reviewing medical records.

                  ∆  Obtaining a copy of medical records.



  ∆  Limits to accessing medical records.

  Relatives and others who have concern for a nursing home resident’s medical condition will often inquire of the staff for medical information or access to the resident’s records.  Such requests made out of concern for the resident’s condition may seem harmless to those making them, but misuse and privacy issues have led to strong regulations dictating who and under what circumstances medical information and records are to be made available to those inquiring.


    This detailed overview or the nursing home resident’s care has the potential of being used in a variety of ways detrimental to the patient. These circumstances have led to making access to nursing home medical records limited and highly regulated through the The Health Insurance Portability and Accountability Act (HIPAA) and the resulting facility’s policy and procedure.  Family members often ask to read or obtain copies of resident medical records but are frustrated by the qualifying standards and/or processes that block their ready access to the information.  Under appropriate circumstances and within the regulations, those records can be made available to an interested party if standards set by the regulations are met.


    With
  few exceptions, other than the nursing facility staff or outsiders providing related care or payment services, only the resident may have access to those documents or determine who else may do so.  The resident in this case would be defined as the person themselves or their personal representative who holds health care power of attorney, is their court ordered guardian, or anyone they designate in writing to see or obtain copies of their records. Being a relative, financial responsible party, or other person in a close relationship with the resident does not qualify one for any health related information from the nursing home without the approval of the resident.


   The Centers for Medicare and Medicaid (CMS) limits release of medical records to another health care institution to which the resident is transferred,  insurance providers, releases allowed by law, and the resident.


    The Health Insurance Portability and Accountability Act produced the Standards for Privacy of Individually Identifiable Health Information rule which requires health care providers to make reasonable efforts to use, disclose, and request only the minimum amount of protected health information needed to accomplish the intended purpose for which the information is being used, disclosed, or requested.  This means the authorized entity requesting the information may not use, disclose, or request the entire medical record for a particular reason unless it can justify the whole record as the amount of information reasonably needed for that purpose.


    This minimum necessary requirement is not imposed in the following circumstances:

    * Disclosure to or a request by a health care provider for treatment;

    * Disclosure to an individual who is the subject of the information or their personal representative;

    * Disclosure to a representative of Health and Human Services for a complaint

        investigation, compliance review, or regulatory enforcement;

    * Use or disclosure that is required by law; or

    * Use or disclosure required for compliance with HIPAA rules.


    HIPAA rules do permit an exception to releasing health care information to a personal representative when the nursing home has a reasonable belief that the personal representative may be abusing or neglecting the individual or that by acknowledging that person as the personal representative, the resident could otherwise be endangered.


  ∆  Reviewing medical records.

  Who will have access to medical records should be established upon admission to the nursing home in anticipation of any future need.  A statement of permission meeting the facility’s policy and procedure in the resident’s medical record would allow concerned and responsible family members to have access to the information.


    With the required authority to view the medical record, it is a good idea to periodically request a meeting with a facility nurse to review a family member’s medical chart.  Attempting to read it on your own would most likely lead to confusion or misinterpretation.  The medical record is developed, organized, and written for use by medical professionals with measurements, terms, and abbreviations not always understandable to the average person.  It is best to use such a review with a nurse as a learning experience and opportunity to work closer with the resident’s care team.


  ∆  Obtaining a copy of medical records.

   Copies of the resident’s current medical record may be obtained by the resident themselves or their properly authorized personal representative.  If older material stored in archive files is also sought, be sure to clearly state so.


    Each facility will have a policy and procedure for requesting and processing medical record copies.  Their procedure must be followed.  They will set the time-line for fulfilling the request within state regulations so the request may not be immediately responded to.  The nursing home will have the option of charging for copies per page within a price limit set by the state.  Discuss the cost before authorizing the copying.  Copying everything could be expensive.


     The
  copy you receive may not contain everything in the residents chart but only those records the nursing home are required to establish and maintain.  This does not mean information is being hidden.  Process memos, reminder notes, or quality assurance work products may be temporarily held in the resident’s chart but are not and do not become a part of the permanent clinical record.  Those items will most likely not be part of the copy.  What you receive should be what is required in the record, not temporary notes used by staff in their daily care processes.


∆  Clinical records as history

    Medical records grow with time, turning into history that does not support current care processes.  As history, the unnecessary material must be preserved without overloading the medical chart binder. The solution to this aging information is a periodic thinning of unnecessary material.  Items that are not critical to the resident’s current medical condition or care plan are removed.


    Thinned material goes into an archive file maintained in the medical records office or other on site location readily available for reference.  All clinical records, thinned or otherwise, must be retained after the date of discharge for the period of time set by state law or for five years if there is no requirement in state law.  For a minor, federal regulations set the retention time as three years after the resident reaches legal age under state law.



For more information on the HIPAA privacy rule go to:

                     http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html


    For more information on nursing home clinical records, use the link below to go to regulation §483.75(l) Clinical Records.

http://www.cms.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf


    For more information on the privacy of nursing home medical records in regulation §483.10(e) Privacy and Confidentiality, click on the following link.

http://www.cms.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf



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