Medical records are the documents that contain “all detail about the patient’s history, clinical findings, diagnostic test results, pre and postoperative care, patient’s progress and medication.” There are a variety of reasons why medical records are typically stored in healthcare facilities, three of which include the following:
- Effective and accurate coordination of care relies on easily accessible and secure medical records.
- Safeguarding medical records is integral to the innerworkings of the healthcare field, as thorough medical documentation reduces the risk of treatment errors, improves the likelihood of a positive outcome, and provides a resource to review cases for opportunities to improve care.
- Medical records provide medical billing specialists with the needed information regarding exact details of services and treatments rendered so they can be properly billed to the insurance company or patient and help reduce malpractice risks.
The government has gone to great lengths to establish national standards and regulations that protect the privacy of certain health information, including medical records.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA), was passed by Congress and signed into law by President Clinton. HIPAA provides universal security provisions and data privacy to ensure the safety, security, and privacy of a patient’s medical information. To adhere to these requirements, the U.S. Department of Health and Human Services published what are commonly known as the HIPAA Privacy Rule and the HIPAA Security Rule. The Privacy Rule, or Standards for Privacy of Individually Identifiable Health Information, addresses how providers and insurance companies are meant to handle patient information by regulating how they disclose the information to each other as well as any other covered entities that may require medical data. According to HIPAA, a patient’s protected health information (PHI) includes the following:
- A patient’s medical record, including past and present medical illnesses, conditions, and treatments
- Fees paid by a patient and/ or a patient’s medical insurance company used to cover healthcare expenses rendered by a healthcare provider
- The location where the patient received care
- The type of healthcare provider seen by the patient
The Security Rule was created with the intention of protecting a person’s information outlining various rules and details how those rules can be enforced, if needed. This rule describes how covered entities must collaborate with one another to properly protect a patient’s medical information, including computerized physician order entry (CPOE) systems as well as electronic healthcare records (EHRs).
Further Information and Support
For most of us, life can be very stressful, leading us to feel emotionally charged, which can cause anxiety, panic attacks, depression, and getting stuck in a cycle of being burdened with negative thoughts. Navigating through the challenges and emotional turmoil of life can be overwhelming, but you do not have to go through it alone. Engage Treatment is a Joint Commission Accredited professional psychological practice. We specialize in treating children, teens, and young adults struggling with depression and anxiety through community-focused treatment plans that incorporate a carefully selected combination of therapeutic interventions. Our compassionate, multidisciplinary practitioners are devoted to providing the highest quality of care that helps ignite positive change and enables clients to reach optimal health and well-being. Please do not hesitate to reach out for guidance. We are happy to answer questions and provide you with any additional information. Feel free to call us at 805-497-0605 or email us at [email protected]. You are also welcomed to get in touch by filling out our contact form. We look forward to connecting and having the opportunity to discuss how we might best be able to support you.