Medical Records in the most simplest definition is the documentation of your health information, diagnostics, treatment, and follow-up (after-care) either kept in a hard copy (paper form) or digitally archived. Most of us never think about medical records, let alone our personal medical records. Yet, our medical history is somewhere out there (hopefully, behind a secure firewall, encrypted, and only accessible by those that intend to help us). Think about this, every time you go to see you Family Physician, Podiatrist, Pediatrician, or Pharmacist your unique medical record(s) is accessed and updated.
Not so long ago, your medical records were kept on paper and written in ink by the Doctor, a Nurse, a Phlebotomist, or a Pharmacist. Today, paper and pen is quickly becoming a thing of the past as HIPAA (Health Insurance Portability and Accountability Act (HIPAA) of 1996) is the driving force behind transitioning to an all DIGITAL format for recording and archiving medical records. Depending on when or where you received medical treatment or diagnostics your records may already be an Electronic Health Record, thus it exist only in a purely digital format. Everything is digitized, everything from your signature on the release of information form to the X-ray of your left foot (or whatever body part was X-Ray-ed). The information is then compiled into a database and accessed on an as needed basis.
Something to always remember and never forget: Your medical information is YOURS. Never let anyone ever tell you otherwise. You can never be denied access to your medical information, however, in some cases physical hard copy access (to take home) may incur a charge. Most states allow a charge for the release of Medical Record in hard copy form, and do so in a highly regulated manner and the maximum allowable fees are maintained and adjusted on an annual basis, by the state. This is to ensure that the information providers are adequately compensated for their time, effort, and expertise in data collecting, processing and delivering on any appropriate request for information.
Because it is your information you should expect that your medical information, in whatever form, is kept secure and protected. This information should ALWAYS be considered HIGHLY CONFIDENTIAL and the release of such information must ALWAYS be HIGHLY CONTROLLED.
Of course there are other people and organizations that will have access to your information, primarily, your insurance provider (they pay the bill) it is also expected that they too will keep your data safe and access to it restricted on a NEED TO KNOW basis and always FOR OFFICIAL USE ONLY.
next time: What is HIPAA?
Technorati Tags: Rio Records Service, Inc., McAllen, Mission, Weslaco, Patient, Doctor, Health Care Provider, Medical Records, Release of Information, ROI, Electronic Health Records, EHR, HIPAA, Health Insurance Portability and Accountability Act, Need to Know, For Official Use Only
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