7/30/2023 0 Comments Are telehealth visits recordedIn addition to HIPAA, some organizations are subject to state laws that provide specific definitions relating to telehealth and medical record documentation/retention. Each healthcare organization is required to define the data or documents that meet this definition. 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. The term “medical record” generally refers to the collection of information regarding a patient and his/her health care. Thus, healthcare providers must understand what they are required to include in the patient’s medical record and provide for the patient upon request. It is important to understand the definition and scope of the term “medical record” because under the Health Insurance Portability and Accountability Act (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,” or DRS. What new mediums must be included in a patient’s medical record? With the addition of the internet, telehealth, and other electronic means of data transmission, the question remains: Typically, the medical record was the patient’s paper file and/or a basic electronic medical record (EMR). In the past, it was easier to define what was and was not considered the “medical record” for a patient. All of these challenges create issues relating to medical record management, maintenance, ownership, and storage. remote monitoring) using and storing numerous file formats (video, audio, text, digital images, film) establishing safeguards for sharing data with virtual providers and distant sites determining the appropriate location for data storage (if more than one provider or entity is involved) and more. Telehealth creates unique health information management challenges for various reasons, including: aggregating large data sets (i.e.
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