The following three categories of data contain secondary patient information and must be afforded the same level of confidentiality as the LMR, but are not considered part of the legal medical record.
A. Patient-identifiable source data are data from which interpretations, summaries, notes, etc. are derived. They often are maintained at the department level in a separate location or database, and are retrievable only upon request.
Examples:
Examples:
1. Photographs for identification purposes
2. Audio recordings of dictation notes or patient phone calls.
3. Video recordings of an office visit, if taken for other than patient care purposes
Acknowledge that there may be older systems that do not have this capability. Future plans for all system to meet this minimum requirement.
4. Video recordings/pictures of a procedure, if taken for other than patient care purposes
5. Video recordings of a telemedicine consultation
6. Communication tools (i.e., Kardex, patient lists, work lists, administrative in-baskets messaging, sign out reports, FYI, drafts of notes, or summary reports prepared by clinicians, etc.)
7. Protocols/clinical pathways, best practice alerts, and other knowledge sources.
8. A Patient’s personal health record provided by the patient to his or her care provider.
9. Alerts, reminders, pop-ups and similar tools used as aides in the clinical decision making process.
The tools themselves are not considered part of the legal medical record. However, the associated documentation of subsequent actions taken by the provider, including the condition acted upon and the associated notes detailing the exam, are considered as component of the legal medical record. Similarly, any annotations, notes and results created by the provider as a result of the alert, reminder or pop-up are also considered part of the legal medical record.
Some source data are not maintained once the data has been converted to text. Certain communication tools are part of workflow and are not maintained after patient's discharge.
B. Administrative Data is patient-identifiable data used for administrative, regulatory, healthcare operations and payment purposes. Examples include but are not limited to:
1. Authorization forms for release of information
2. Correspondence concerning requests for records.
3. Birth and death certificates.
4. Event history/audit trails.
5. Patient-identifiable abstracts in coding system.
6. Patient identifiable data reviewed for quality assurance or utilization management.
7. Administrative reports.
C. Derived Data consists of information aggregated or summarized from patient records so that there are no means to identify patients. Examples:
1. Accreditation reports
2. Best practice guidelines created from aggregate patient data.
3. ORYX reports, public health records and statistical reports.
D. Draft Documents / Work in Progress. Electronic processes and workflow management require methods to manage work in progress. These work-in-progress documents often are available in the system as “draft documents, viewable to a limited number of users.
They generally are not viewable to clinicians until the document is sent for final signature. Draft documents are not considered an official medical record document until it has been signed by an authorized signer.
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