Title 4-301 - 4-309, 8-601. Medical Records Act Flashcards
What is a personal note? 2 parts!
= info that is:
1) the work product and personal property of a mental health provider and
2) except in certain circumstances (see exceptions flash card), not discoverable or admissible as evidence in any criminal, civil, or administrative action.
What is a medical record? Hint: there are 3 characteristics.
= any oral, written, or other transmission in any form or medium of info that:
1) is entered in the record of a patient or recipient
2) identifies or can readily be associated with the identity of a patient or recipient
3) relates to the health care of a patient or recipient
What are the 3 necessary conditions to ensure that a personal note is not included in a patient’s medical record?
1) the mental health care provider (MHCP) keeps the PN in their sole possession for the MHCP’s own personal use.
2) maintains the PN separate from the recipient’s medical records.
3) does not disclose the PN to any other person except:
a) MHCP’s supervising HCP;
b) a consulting HCP;
c) an attorney of the HCP;
Note: all of whom maintain the confidentiality of the PN.
What 5 pieces of information does the Personal Note NOT include?
= info concerning the patient’s diagnosis, treatment plan, symptoms, prognosis, or progress notes.
What are 2 exceptions to a PN? That is, when WILL a PN be considered part of a recipient’s medical record?
1) …if, at any time, a MHCP discloses a PN to a person other than the provider’s supervising HCP; a consulting HCP; or an attorney of a HCP (all of whom maintain the confidentiality of the PN); or….
2) if a MHCP discloses a PN to a recipient who has initiated an action for malpractice, an intentional tort, or professional negligence against the MHCP. That is, this is one exception such that the disclosure, discovery, or admissibility of a PN is not prohibited.
Generally speaking, what is one of a psychologist’s main duties when it comes to a client’s medical record?
To keep the medical record of a patient or recipient confidential and disclose the medical record only as stated in subtitle 4-302 or as otherwise provided by law.
What are 4 rules for disclosure of a medical record upon authorization of a person in interest?
An authorization shall:
1) be in writing, dated, and signed by the person in interest
2) state the name of the HCP
3) identify to whom the information is to be disclosed
4) state the period of time that the authorization is valid which may not exceed 1 year, except:
(1) in cases of criminal justice referrals; and
(2) in cases where the client is a resident of a nursing home.
What are 2 exceptions to the rules re: disclosure upon authorization?
1) pre authorized insurance forms
2) authorization for release related to workers’ compensation
Otherwise, a HCP shall disclose a medical record on the authorization of a person in interest in accordance with the 4 specific rules of this section.
What are the 3 rules re: revocation of authorization for disclosure of a medical record?
1) except in cases of criminal justice referrals, a person in interest may revoke an authorization in writing.
2) a revocation of an authorization becomes effective on the date of receipt by the HCP.
3) a disclosure made before the effective date of a revocation is not affected by the revocation.
What 3 things are entered into the medical record having to do with authorizations and revocations of authorizations to disclose the medical record?
1) a copy of a written authorization
2) a copy of any action taken in response to an authorization
3) a copy of any revocation of an authorization
After a person in interest requests a medical record in writing, what must a psychologist do?
The psychologist must comply with the request within a reasonable time after receiving the request. Within 21 working/business days is considered a “reasonable amount if time.”
If the HCP believes that disclosure of any part of the medical record would be injurious to the health of a patient or recipient, what may s/he do?
= refuse to disclose that part of the medical record, but , on written request, shall:
1) make a summary of the undisclosed portion available to the patient, recipient, or person in interest (and write “summary” across the top of each summarized page)
2) insert a copy of the summary in the medical record of the patient or recipient
3) permit examination and copying of the medical record by another HCP who is authorized to treat the patient for the same condition as the HCP denying the request
4) inform the patient or recipient of his/her right to select another HCP, who may receive the entire record and may then decide if the patient should have access to the whole record or to just the summary
What are the specific copying and preparation fees that a HCP may require the person in interest (or any other authorized person) who requests a copy of the medical record to pay?
1) for copying and mailing: 73 cents per page
2) a preparation fee not to exceed $22.18 for medical record retrieval and preparation
3) the actual cost for postage and handling of the medical record
What are 4 of the main reasons that a HCP may disclose a medical record without the authorization of a person in interest?
1) ADMIN - to the HCP’s authorized employees, agents, medical staff, medical students, or consultants for the sole purpose of providing, evaluating, or seeking payment for healthcare to patients/recipients by the HCP (e.g., to the HPC’s legal counsel only as pertaining to the subject matter of the representation; to the HPC’s insurer or legal counsel, or the authorized employees/agents of these people, for the purpose of handling a claim against the HPC).
2) EMERG - to provide for the emergency health care needs of a patient or recipient.
3) CONSULT - to another licensed HCP for the purposes of providing quality health care to the patient.
4) COMP PROCESS - compulsory process - subpoena, summons, warrant, or court order that appears on its face to have been issued on lawful authority (e.g, in investigation or treatment in a case of suspected abuse or neglect of a child or adult; to health professional licensing/disciplinary boards for the purpose of investigation; investigating criminal activity).
