Policy & Procedures for the Release of Medical Records
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Policy and Procedures for the Release of Medical Records
POLICY
It shall be the sole responsibility of BRAVO Healthcare Assisted Living Facility to provide each patient with a copy of its policy and procedures which outline the guidelines for the release of medical records while maintaining the patients rights to confidentiality.
GUIDELINES
The release of any information dealing with a patient at this facility, written or verbal, which has NOT been properly authorized, is considered a breach of trust and ethical practice. The Privacy Act of 1974, which BRAVO Healthcare Assisted Living Facility upholds, provide private citizens control over the information collected about them by limiting the use of information for un-necessary purposes (Fremgen, 2012). Under this act patients have the right to review information collected by the government, order a copy of the information, and make necessary corrections. This gives patients a sense of empowerment over their personal information.
PROCEDURES
No phone calls or email messages for the release of medical records will be accepted only an authorized medical release form the patient has signed and put their information on can be faxed or mailed to the facility to release their records to the facility of their choice.
Proper authorization which gives BRAVO Healthcare Assisted Living Facility permission to disclose a patients confidential information submitted MUST include the following information:
Patient name and signature.
Purpose of request for medical information.
Nature of the information to be released.
Inclusive dates of treatment.
Date, event, or condition upon which the authorization will expire.
Date that consent is signed and witnessed.
NOTE: In the case of minors or patients who have been deemed legally incompetent, authorization MUST be signed a guardian or legal representative. If the patient is deceased, the administrator or executor of the deceased patients estate is required to sign off on the necessary authorization forms.
Confidentiality and Medical Record Policy and Procedures
POLICY
BRAVO Healthcare Assisted Living Facility firmly upholds the laws surrounding patient confidentiality. Patients medical information CAN NOT and WILL NOT be released without written consent from the patient, or other legally authorized representative.
GUIDELINES
BRAVO Healthcare Assisted Living Facility guidelines are governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Confidentiality of a medical record is not a concern if all guidelines are followed. The medical record policy protects the patient health records per legal requirements.
PROCEDURE
BRAVO Healthcare organization will only release the patients requested information for the specific purpose stated in the written authorization to the approved individual or agency. Patient medical information cannot be release if the patient is under the age of 18. not 18 or older. Safeguard of a medical record covered by laws governed by state and federal laws. Any medical professional that handles patient information has to sign a confidentiality statement. This assures the patient health information is handled correctly. Patient information is filed or stored and restricted from public entry.
Ownership, Responsibility and Security of Medical Records
POLICY
According to the Patients Bill of Rights a patients has the right to access his or her medical record. However, any patient requesting complete medical chart be sent to another location WILL BE CHARGED a copying fee. Medical records are the property of BRAVO Healthcare organization; therefore, the original medical record will be housed within this facility. Note: Intra-Agency transfer of charts will not require copying, a fee, nor release form.
GUIDELINES
All Medical Records of patients and patient lists and billing information, are the property of “BRAVO Healthcare Assisted Living Facility”. The information contained within the Medical Record must be accessible to the patient and shall be made available to the patient or his or her legal representative upon request and authorization by the patient or his or her legal representative.
The Health Information Manager (HIM) is designated as the person responsible for assuring that there is a complete and accurate medical record for every patient. The medical staff and other health care professionals are responsible for the documentation in the medical record within required and appropriate time frames to support patient care.
Original records may not be removed except by court order, subpoena,