# records that match search criteria: 10
Term:
Definition:
Policy:
View:
TermDefinition
Administrative Data Data used for administrative, regulatory, operational and financial purposes (e.g. charge tickets, requisitions, death certificates, authorization forms for disclosure of information, event history and audit trails, patient identifiable claims, patient identifiable data for quality assurance and management purposes, protocols, clinical pathways, practice guidelines and other knowledge sources that do not imbed patient data).
Case Management File/Shadow Medical Record (CMR) A medical record maintained by a specific physician or department that only includes copies of original patient care information  already in the UMR.  Commonly referred to as “shadow records,” CMRs are considered convenience copies only and have no record retention schedule.  CMRs should never contain original medical records.
De-identification

Data or information aggregated or summarized from patient records so that no means exist to identify the patient (e.g. management and quality management reports, case studies that do not identify the patient, statistical reports, anonymous data used for research purposes). See IHOP policy 6.2.29, De-Identification of PHI, for more information.

 

De-identified Data

Data or information aggregated or summarized from patient records so that no means exist to identify the patient (e.g. management and quality management reports, case studies that do not identify the patient, statistical reports, anonymous data used for research purposes). See IHOP policy 6.2.29, De-Identification of PHI, for more information.

Designated Record Set

  A group of records maintained by or for UTMB that are:

  1. The medical records and billing records about patients maintained by or for UTMB;
  2. The enrollment, payments, claims adjudication, and case or medical management record systems maintained by or for a health plan; or
  3. Used, in whole or in part, by or for UTMB to make decisions about patients.
HIM Satellite Operations HIM may delegate or appoint management of the SMRs to individuals approved by HIM.  Original medical records managed by HIM satellite operations will be considered part of the UMR.  HIM must be consulted before a department other than HIM plans to maintain original medical records.
Medical Record Custodian The person or department responsible for the maintenance, retention, access, data integrity, and data quality of Protected Healthcare Information (PHI); including protecting patient privacy and providing information security, analyzing clinical data for research and public policy, preparing PHI for accreditation surveys, and complying with standards and regulations regarding PHI.
Source Data

Data from which interpretations, summaries, or notes are derived, regardless of media. This data includes health information stored in any original media. Examples of Source Data include, but are not limited to, paper diagnostic tests or tools, x-rays, videotapes, ultrasounds, fetal monitor strips, photographs (either conventional photos or digital images), and ancillary or supporting systems (e.g. . pharmacy information systems and radiation oncology information systems). These forms of Source Data have unique retention schedules. The UMR must contain a written interpretation of all Source Data. Source Data is distinct from the written interpretations of significant clinical information that is included in the UMR and is not part of the official UTMB Legal Medical Record.

Subsidiary Medical Record (SMR) A medical record maintained by a department other than HIM, which contains original/official information in paper or electronic form concerning outpatient health care administered by UTMB health care providers to UTMB patients.  SMRs are subsets of the UMR.
Unit Medical Record (UMR)

The official UTMB legal medical record maintained by the Department of Health Information Management (HIM) that contains UTMB’s original/official patient care information.  The UMR is designed to contain the written interpretations of all significant clinical information gathered for a given patient, whether as an inpatient, outpatient, or emergency care patient. The entire patient’s medical record is thus in paper and /or electronic form under one hospital number. UMR’s have a permanent retention schedule.

All policy documents are the property of The University of Texas Medical Branch and,
with few exceptions, may not be used, distributed, or reproduced outside of UTMB without written permission.
To request written permission, ask a question about this site, or report a broken link, please contact the IHOP Coordinator.