I. Maintenance of the Medical Record
A. A Medical Record shall be maintained for every individual who is evaluated or treated as an inpatient, outpatient, or emergency patient of a UC__ hospital, clinic, or physician’s office.
B. Currently, the Medical Record is considered a hybrid record, consisting of both electronic and paper documentation. Documentation that comprises the Medical Record may physically exist in separate and multiple locations in both paper-based and electronic formats. (See Appendix A).
C. The medical record contents can be maintained in either paper (hardcopy) or electronic formats, including digital images, and can include patient identifiable source information, such as photographs, films, digital images, and fetal monitor strips and/or a written or dictated summary or interpretation of findings.
D. The current electronic components of the Medical Record consist of patient information from multiple Electronic Health Record source systems. The intent of UC__ is to integrate all electronic documents into a permanent electronic repository.
E. Original Medical Record documentation must be sent to the designated Medical Records department or area. Whenever possible, the paper chart shall contain original reports. Shadow files maintained by some clinics or care sites contain copies of selected material, the originals of which are filed in the patient’s permanent Medical Record.
II. Confidentiality
The Medical Record is confidential and is protected from unauthorized disclosure by law. The circumstances under which UC__ may use and disclose confidential medical record information is set forth in the Notice of Privacy Practices (see: Privacy Policy and Procedure No. _____, “Notice of Privacy Practices”) and in other UC__ Privacy Policies and Procedures.
III. Content
A. Medical Record content shall meet all State and federal legal, regulatory and accreditation requirements including but not limited to Title 22 California Code of Regulations, sections 70749, 70527 and 71549, and the Medicare Conditions of Participation 42 CFR Section 482.24. Appendix A contains a listing of required Medical Record documentation content, and current electronic or paper format status.
B. Additionally, all hospital records and hospital-based clinic records must comply with the applicable hospital’s Medical Staff Rules and Regulations requirements for content and timely completion.
C. All documentation and entries in the Medical Record, both paper and electronic, must be identified with the patient’s full name and a unique UC__ Medical Record number. Each page of a double-sided or multi-page forms must be marked with both the patient’s full name and the unique Medical Record number, since single pages may be photocopied, faxed or imaged and separated from the whole.
D. All Medical Record entries should be made as soon as possible after the care is provided, or an event or observation is made. An entry should never be made in the Medical Record in advance of the service provided to the patient. Pre-dating or backdating an entry is prohibited.
IV. Medical Record vs. Designated Record Set
A. Under the HIPAA Privacy Rule, an individual has the right to access and/or amend his or her protected health (medical record) information that is contained in a “designated record set.” The term “designated record set” is defined within the Privacy Rule to include medical and billing records, and any other records used by the provider to make decisions about an individual. In accordance with the HIPAA Privacy Rule, UC__ has defined a “designated record set” to mean the group of records maintained for each individual who receives healthcare services delivered by a healthcare provider, which is comprised of the following elements:
- The Medical Record whether in paper or electronic format, to include patient identifiable source information such as photographs, films, digital images, and fetal monitor strips when a written or dictated summary or interpretation of finding has not been prepared;
- Billing records including claim information; and
- All physician or other provider notes, written or dictated, in which medical decision-making is documented, and which are not otherwise included in the Legal Medical Record (e.g., outside records, email when applicable for treatment).
B. The Medical Record generally excludes records from non-UC providers (i.e., health information that was not documented during the normal course of business at a UC__ facility or by a UC__ provider). However, if information from another provider or healthcare facility, or personal health record, is used in providing patient care or making medical decisions, it may be considered part of the UC__ Designated Record Set, and may be subject to disclosure on specific request or under subpoena. Disclosures from medical records in response to subpoenas will be made in accordance with applicable Campus policies.
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