MEDICAL RECORD INFORMATION IS CONFIDENTIAL AND PRIVILEGED
INFORMATION, AND IS
LEGALLY PROTECTED FROM DISCLOSURE
As you use the medical record information and
discuss patients with your colleagues, be sure to do so in a private area. Even
accidental release of information is unlawful disclosure. Please be sensitive to every patient’s right
to privacy.
All medical record information created on
your patients is to be incorporated into the UTMB medical record as soon as
possible. This is to insure a complete
medical record for:
Continuity
of patient care
Legal
protection for UTMB and the physician
Legally
required retention period
Financial
and quality audits by third party payers
Research,
statistics, and teaching purposes
Failure to maintain a complete, adequate and timely medical record could lead to a finding that you were negligent in treating your patient.
Numerous laws govern the release of
confidential medical record information.
Refer all requests for release of medical record information to the
Information Release Services Section of the Health Information Management
Department-Extension #21965.
If you need medical record information on a
patient which was created by another health care provider, complete Form #7034,
“Request for Information” (located on inpatient units and in clinic areas),
obtain patient’s signed authorization on the form, and mail. If you need assistance, contact the Health
Information Management Department-Extension #21965.
Both civil and criminal laws make the medical
record the legal property of the UTMB Hospitals, and its unauthorized removal
may be criminal theft. All information
in the record is CONFIDENTIAL
and should be treated as such at all times.
To ensure the confidentiality of the medical records, records will only
be released to authorized requesters presenting a valid UTMB badge. Medical records are not to be taken from the
UTMB Hospitals. If a subpoena duces
tecum is received to produce a medical record in court, it shall be directed
only to the Subpoena Coordinator in the Health Information Management
Department. Anyone else removing a
medical record from the University of Texas Medical Branch Hospitals is risking
serious medicolegal actions and is subject to severe disciplinary action
including suspension or termination. The
medical record is the legal property of the UTMB Hospitals and should always
remain in the custody of UTMB’s Health Information Management Department.
INFORMATION
RELEASE SERVICES
All legal requirements must be met before
releasing medical information to individuals or agencies not affiliated with
UTMB. All requests for medical record
information are to be forwarded to the Health Information Management
Department, Release of Information Section, Ext. 21965, Route 0782.
When a patient is transferred to another
healthcare facility and medical information must be copied and sent with the
patient, the patient’s consent is to be obtained on Form #7032-2 (attached). This form authorizes release of incomplete
information for patient care purposes.
It must be signed by the patient and the physician.
The Health Information Management Department
is open 24 hours per day, seven days per week in order to retrieve records for
patient care. The Health Information
Management Department delivers records to UHC, PCP clinics and the
Physicians and other ancillary personnel may
request records provided they are authorized to do so by their own department
and the Health Information Management Department. Physicians need to fill out the necessary
form and submit it to the Health Information Management Department. This is done through the
Incomplete records of patients readmitted
will remain on inpatient floor for 72 hours and then returned to Record
Processing for completion. All
records loaned to clinics must be returned to Health Information Management the
same day.
Record Access Policy: Strict enforcement of the Record Access
Policy, #9.2.6, is maintained; i.e., all records returned the same day
received. No incomplete record will
leave the Record Processing or Health Information Management satellite area
unless specifically requested for patient care.
Physicians requesting medical records for
research may call Ext. 21775 for assistance.
A written request for research is required. Research for publication or presentation outside
of UTMB must have Institutional Review Board (IRB) approval, Ext. 23482.
Physicians needing statistical information
may call Ext. 70383 for assistance.
House Staff physicians are required to have a
faculty physician co-sign the research or statistical request.
Research records must be reviewed in the
Health Information Management Department.
Ten records per day may be pulled for review. Copying of the medical record is not
permitted.
The Medical Record Request Center (MRRC) is a
service provided by the Health Information Management Department (HIM) to the
hospital to enable the requesters, who have gone through the MRRC approval
process, a way in which to request UTMB medical records for reasons other than
patient care, research, or completion.
Location/Hours: The MRRC representative is currently in
Room 3.300 McCullough
Building, Ext. 22400 and is
open from
Approval Process: Persons who want access to medical records
for non-direct patient care purposes and have a legitimate need for these
records can apply for their individual code numbers. Faculty physicians will automatically receive
a requester/dictation ID number. Upon
completion of an application (attached), specific codes identifying you will be
assigned. Because these codes are
specific to you, we ask that you not “lend” them to others. If you choose to do this, you are responsible
for the record and its return to the Health Information Management
Department. Furthermore, sequestering
of record in places such as lockers and desks or in any other way making a
record unavailable for immediate access makes the person responsible
susceptible to appropriate disciplinary action.
Procedure
for Non-Direct Medical Record Request
Purpose:
1.
To determine medical record location.
2.
Retrieve requested record.
3.
Update record location in the HIM Department’s SoftMed
tracking system.
Procedure: Request
for medical records can be delivered to the HIM Department at 3.300
1.
All new requestors must complete an application to
receive a requestor code. Applications
are available at the
2.
All medical record requests, either slips or list,
must be in terminal digit order according to last two digits (00-99). The request must have requestor’s code,
requestor’s name, extension number and department.
3.
Search for only two requested records while the requestor
waits. Any remaining requests are to be
left and retrieved for the requestor within stated TAT (turn-around-time) 8-10
working days.
If the medical record is in Record Processing/Coding:
1.
If the record is needed for direct patient care, have
the requestor write “Patient Care” on the request slip and direct him/her to
Record Processing.
2.
IF the request is needed for non-direct patient care
and the chart is in RP/Coding, we will let the requestor know and direct them
to RP.
ALL RECORDS ARE TO BE RETURNED TO H.I.M. BY
THE
HEALTH
INFORMATION MANAGEMENT DEPARTMENT
CONFIDENTIALITY
POLICY
Applicable To: All hospital employees, medical
staff, and students.
Purpose: To protect patient rights
of confidentiality.
9.2.11 A. All medical records, personal data, and/or
health status data about any patient are confidential. While patient information may be communicated between hospital
personnel for the purpose of caring for the patient, casual
discussions regarding a patient, discussion in public areas,
and/or unauthorized release of information are not in the best
interest of the patient or the hospital and are a breach of the UTMB
Standards of Employee Conduct.
B. Abuse of this policy shall lead to
disciplinary action and/or termination.
References: UTMB Institutional Handbook of
Operating Procedures
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
BASIC STEPS IN REQUESTING MEDICAL RECORDS FROM THE REQUEST CENTER ROOM
#3.310,
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
1. Information
on the 24-hour request slips should be accurate, complete, and legible.
2. You must know your requester codes,
please write them on the request slip as this will expedite the retrieval of
the medical records.
3. Your
complete signature on the request slip and a valid UTMB badge are required when picking up records from the Health
Information Management Department.
4. Place
additional request slips in the designated box.
These records may be picked up
within 5 working days.
5. All medical records are to be returned by
6. If
any previously requested record is delinquent in being returned to the Health Information Management Department or if the
number of records checked out exceeds
the limit (10 records), you will not be able to receive additional records.
7. At
the time all overdue records are returned and have been checked in to the Records Management Division on the computer,
you may again request your limit.
8. The
Request Center desk is open from
9. If
you are not completely finished with the record at the end of the day, please return the record to Room 3.300 McCullough
Building and request that it be held overnight
in the 24-hour Hold Area. The record will
then be available to you the following
morning.
10. If
you are completely finished with the record(s), please return the record(s) to 3.300
ATTACHMENT
B
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GUIDELINES FOR RELEASE OF STATISTICAL INFORMATION
1. No
release of TDCJ information without approval from the Executive Director for Texas Department of Criminal Justice.
2. All
requests outside of UTMB must be received in writing. These requests will be forwarded to the Vice President for
Clinical Affairs for approval.
3. All
financial class requests will be referred to Patient Finance.
4. All
requests within UTMB for statistical reports require the completion of a form stating information needed and the
reason for the need.
5. Requesters
of information must obtain the signature of their authorized Department Director/Chairman, Executive
Director, or Sponsoring Faculty Member.
STATISTICS HOURS:
STATISTICS TEAM LEADER: Judy Sturgeon
EXTENSION: x22943
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Attachment B
Release of Information