Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 1 › Subtitle 01 - PROCEDURES › Chapter 10.01.16 - Retention and Disposal of Medical Records and Protected Health Information › Section 10.01.16.02 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this chapter,
				  the following terms have the meanings indicated.
B. Terms Defined.
(1) "Divisible" means a medical record that
				  is amenable to separation or division after the expiration of the retention
				  time stated in Regulation .04 of this chapter.
(2) Health Care Provider.
(a) "Health care provider" means an
				  acupuncturist, audiologist, chiropractor, dietician, dentist, electrologist,
				  massage therapist, mortician, nurse, nutritionist, occupational therapist,
				  optometrist, physical therapist, physician, podiatrist, professional counselor,
				  psychologist, social worker, speech-language pathologist, or a health care
				  facility or entity that is a:
(i)
				  Freestanding, ambulatory care facility as defined in Health-General Article,
				  § 19-3 B-01, Annotated Code of Maryland;
(ii) Freestanding medical facility as defined
				  in Health-General Article, § 19-3 A-01, Annotated Code of
				  Maryland;
(iii) Health maintenance
				  organization as defined in Health-General Article, §19-701, Annotated Code
				  of Maryland;
(iv) Hospital as
				  defined in Health-General Article, §19-301, Annotated Code of
				  Maryland;
(v) Limited service
				  hospital as defined in Health-General Article, §19-301, Annotated Code of
				  Maryland;
(vi) Related institution
				  as defined in Health-General Article, §19-301, Annotated Code of
				  Maryland;
(vii) Residential
				  treatment center as defined in Health-General Article, §19-301, Annotated
				  Code of Maryland; and
(viii) Health
				  care facility as defined in Health-General Article, §10-101, Annotated
				  Code of Maryland.
(b)
				  "Health care provider" includes an agent, officer, director, or employee of any
				  entity listed in §B(2)(a) of this regulation.
(3) Medical Record.
(a) "Medical record" means any oral, written,
				  or other transmission in any form or medium of information that:
(i) Is entered in the record of a
				  patient;
(ii) Identifies or can
				  readily be associated with the identity of a patient; and
(iii) Relates to the health care of the
				  patient.
(b) "Medical
				  record" includes any:
(i) Documentation of
				  disclosures of the medical record to any person who is not an employee, agent,
				  or consultant of the health care provider;
(ii) File or record maintained under Health
				  Occupations Article, §
													12-403(b)(13),
				  Annotated Code of Maryland, by a pharmacy of a prescription order for drugs,
				  medicines, or devices that identifies or may be readily associated with the
				  identity of a patient;
(iii)
				  Documentation of an examination of a patient regardless of who requested the
				  examination or is making payment for the examination;
(iv) File or record received from another
				  health care provider that relates to the health care of a patient received from
				  that health care provider, and identifies or can readily be associated with the
				  identity of the patient; and
(v) To
				  the extent not narrowed by §B(3)(a) and (b)(i)-(iv) of this regulation,
				  "protected health information" as defined by
				  45 CFR §
														160.103, as amended.
(4) "Medical records series" means
				  a set of medical records, as defined in §B(3) of this regulation, that is
				  maintained on paper, microform, magnetic disk, magnetic tape, or other
				  medium.
(5) "Patient" has the
				  meaning stated in Health-General Article, §4-301(j), Annotated Code of
				  Maryland.
(6) "Person in interest"
				  has the meaning stated in Health-General Article, §4-301(k), Annotated
				  Code of Maryland.
(7) "Records
				  management service" means any agent that has been procured by a health care
				  provider to transport, handle, manage, maintain, store, or destroy medical
				  records.
(8) "Records retention
				  schedule" means a records management plan that includes:
(a) A list and description of the medical
				  records series of an office or unit;
(b) The minimum retention period required to
				  keep each medical record series;
(c) The eventual disposition
				  instructions;
(d) If desired:
(i) Maintenance procedures, such as access or
				  copy control, for each medical records series both in office and in
				  storage;
(ii) Scanning or
				  microfilming instructions; or
(iii)
				  Disposal methods such as shredding or incineration; and
(e) A signature of approval by an individual
				  with authority over all the medical records series listed.
(9) "Sanitizing" means overwriting,
				  degaussing, shredding, or burning electronic or other media.