Definitions Legal Health Record: The legal health record is the officially declared record of healthcare services provided to an individual delivered by a provider. It is the record that would be released upon receipt of an authorized request. Designated Record Set: A group of records maintained by or for a covered entity that is: (1) the medical and billing records about individuals maintained by or for a covered health care provider; (2) enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan; or (3) used, in whole or in part, by or for a HIPAA covered health care provider to make decisions about individuals. For purposes of a designated record set, "record" means any item, grouping, or collection of information that includes protected health information (as such term is defined in 45 C.F.R. § 160.103) and is maintained, collected, used, or disseminated by or for a covered entity. Not all records that are part of the designated record set will belong in the legal health record. Clinical Record: A group of records created for and/or used for the clinical care of the patient. The clinical record belongs in both the legal health record and the designated record set. Examples of clinical records include: History and physical Orders and Results Progress notes Lab reports (including contract lab reports) Progress notes Vital signs Assessments Consults Clinical reports Authorizations and consents Source Clinical Data: Data created and/or used in the development of the Clinical Record. Such data belongs in both the legal health record and the designated record set. Examples of source clinical data include, but are not limited to: X-rays Images Fetal strips Videos Pathology slides External Records and Reports: Available records and reports generated outside of [organization]. Such records and reports may or may not belong in the designated record set and legal health record. Examples of external records and reports include, but are not limited to: External records referenced for patient care: other providers’ records, records provided upon transfer Patient generated records Personal health records Committee Reports of Patient-Specific Care Decision: Hospital Committee reports reflecting decisions impacting patient care should not be kept in the record. In those circumstances,
Inpatient ER Dr./Nurse Reports B Inpatient ER Orders, Vitals, Etc. B Inpatient Ambulance Reports B Inpatient Code Blue Forms B Outpatient ER Orders, Vitals, Etc. B Outpatient ER Ambulance Report B Outpatient ER Code Blue Forms B Discharge Summary B 48 Hr. Discharge Summary B Consultations B Old Records-other facilities DRS [NOTE: Are these records ever used to provide the patient with health care services? If so, this might change to "B."] Nursing Home Reports DRS [NOTE: Are these records ever used to provide the patient with health care services? If so, this might change to "B."] Copies of treatment from other facilities/providers DRS [NOTE: Are these records ever used to provide the patient with health care services? If so, this might change to "B."] Surgery: Operative Report B Pathology Report B Operative Pictures B Endoscopy Record B Anesthesia Record B
Operating Rm. Nursing Assess. B “Yellow” EKG Sheets B Post Anesthesia/RR Record B Pre-operative Checklist B Consents: Initial Treatment B Surgical/all types of procedures B Delivery Summary B Physician Progress Notes B Diagnostic and Therapeutic Orders B Medication Reconciliation Form B Transfusion Sheets B Lab Results B Reference Lab Results B Radiology Reports B X-ray films/images, videos B EKGs: Electrocardiogram B Dictated Results B Mounted Strips B Echocardiogram Report B Stress Test Report B Pulmonary Function: Reports B Records (graphs, etc.) B Other Diagnostic Results B Therapy (Rehab): Initial Evaluation B