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  • Preface
  • Introduction
  • Chapters 1 – 4
    • Chapter 1: Introduction To The Health Record
    • Chapter 2: General Release of Information
    • Chapter 3: Authorizations
    • Chapter 4: Required Disclosure Statements
  • Chapters 5 – 8
    • Chapter 5: Legal Process
    • Chapter 6: Mental Health Records
    • Chapter 7: Substance Abuse Records
    • Chapter 8: HIV/AIDS
  • Chapters 9 – 12
    • Chapter 9: Ambulatory Care Records
    • Chapter 10: Long Term Care & Rehabilitation
    • Chapter 11: Hospice And Home Health Records
    • Chapter 12: Faxing
  • Chapters 13 – 15
    • Chapter 13: Risk Management
    • Chapter 14: Record Retention and Destruction
    • Chapter 15: Electronic Health Information
  • Glossary of Terms
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Health Records in Pennsylvania: A Guide to State and Federal Statutes, Rules, Regulations, and HIPAA Guidelines

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Chapter 1: Introduction To The Health Record
  • Definition and Purpose
  • Confidentiality and Privacy of Health Information
Chapter 2: General Release of Information
  • Ownership and Access to the Health Record
  • Release of Information Overview
  • Charging for Providing Copies of Health Records
  • Federal Statutes and Regulations
  • State Statutes and Regulations
Chapter 3: Authorizations
  • Introduction
  • Core Elements of a Valid HIPAA Authorization
  • Required Statements
  • Other
  • –Psychiatric Records
  • –HIV-related Records
  • –Drug and Alcohol Treatment Records
  • –Plain Language Requirement
  • –Defective Authorizations
  • Compound Authorizations
  • Revocation of Authorizations
  • Notes (Chapter 3)
Chapter 4: Required Disclosure Statements
  • Introduction
  • Substance Abuse Records
  • Mental Health Records
  • HIV
  • Fax Requirements
  • Health Records and Authorized Recipients
  • Notice of Privacy Practices
  • Notes (Chapter 4)
Chapter 5: Legal Process

  • Introduction
  • Attorney/District Attorney Requests
  • Subpoenas
  • Types of Subpoenas
  • Responding to a Subpoena
  • Out of State Subpoenas
  • Court Orders
  • Search Warrants
  • Depositions
  • Interrogatory
  • Testimony in a Court Room or at a Deposition
  • Electronic Discovery Civil Rule
  • Coroner/Medical Examiner
  • Community Legal Services
  • Notes (Chapter 5)
Chapter 6: Mental Health Records
  • Mental Health / Psychiatric Records
  • Confidentiality
  • Access to Mental Health Record Information
  • Psychotherapy Notes
  • Judicial Access
  • Content of Patient Authorization to Release Mental Health Information
  • A Re-disclosure Statement to Accompany Information Released
  • Patient Age for Authorization to Release Mental Health Information
  • Patient Access to His or Her Health Record
  • Amendment of Records
  • Patient Presence in Mental Health Facility
  • Notes (Chapter 6)
Chapter 7: Substance Abuse Records
  • Introduction
  • Release Requirements
  • Release Without Authorization
  • Disclosure Statement
  • Blood Alcohol Levels
Chapter 8: HIV/AIDS
  • Introduction
  • Permissible Disclosures Without Consent
  • Required Elements of the Authorization
  • Disclosure Statement
Chapter 9: Ambulatory Care Records
  • Introduction
  • Hospital-Based Outpatient Services
  • Notes (Chapter 9)
Chapter 10: Long Term Care & Rehabilitation
  • Introduction
  • State Licensure Requirements
  • Record Oversight
  • Record Content
  • Record Completion
  • Oral and Telephone Orders
  • Record Retention
  • Confidentiality
  • Facility Closing
Chapter 11: Hospice and Home Health Records
  • Hospice
  • Documentation
  • Regulation and Accreditation
  • Record Content
  • Record Security
  • Supervision of Home Health Aide Services
  • Patient Instructions
  • Voluntary Accreditation for Hospice Programs
  • Reimbursement Requirements
  • Home Health
  • Federal Level Requirements
  • State Licensure Requirements
  • Record Content
  • Physician Orders
  • Routine Review of Plan of Treatment and Continuation of Care
  • Quarterly Clinical Record Review
  • Record Retention
  • Copies of Record at Transfer
  • Confidentiality
  • Additional Information
  • Notes (Chapter 11)
Chapter 12: Faxing
  • Introduction
  • Reasonable Safeguards
  • Forms and Cover Letter
  • Misdirected Fax Letter
  • Verification of Receipt of Confidential Patient Information
  • General Procedures
  • Notes (Chapter 12)
Chapter 13: Risk Management
  • Introduction
  • HIM and Risk Management
  • Incident Reporting
Chapter 14: Record Retention and Destruction
  • Introduction
  • Retention Timeframes
  • Retention Policy
  • Record Destruction
  • Acquisitions, Mergers or Closings
  • Retention of Other Records
  • Definitions
  • Health Record Retention Regulations
  • Contractual Obligations for Health Record Retention
  • Maintenance of Health Records of Minors
Chapter 15: Electronic Health Information
  • Introduction
  • Legal EHR Definition
  • Storage Considerations
  • Release of Information with EHRs
  • Confidentiality and Data Security
  • HIPAA Privacy and Security Rule Relationships
  • Security Rule
  • Security Safeguards
  • Administrative Safeguards (§164.308)
  • Physical Safeguards (§164.310)
  • Technical Safeguards (§164.312)
  • Business Associate Contracts or Other Arrangements (§164.314(a)(1))
  • Organizational, Policies & Procedures, & Documentation Requirements
  • Policies and Procedures (§164.316(a))
  • Documentation (§164.316(b)(1))
  • Joint Commission-Management of Information (IM)
  • Pennsylvania State Department of Health Regulations
  • Automation of Health Records (§115.26)
  • Storage of Health Records (§115.22)
  • Confidentiality of Medical Records
  • Authentication in Electronic Health Records
  • Corrections to Electronically Signed Documents
  • The Electronic Health Record As a Legal Business Document

Revision History

January 2022

  • Charging for Providing Copies of Health Records

November 2021

  • Subpoenas
  • Types of Subpoenas

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Table of Contents

  • Preface
  • Introduction
  • Chapter 1: Introduction To The Health Record
  • Chapter 2: General Release of Information
  • Chapter 3: Authorizations
  • Chapter 4: Required Disclosure Statements
  • Chapter 5: Legal Process
  • Chapter 6: Mental Health Records
  • Chapter 7: Substance Abuse Records
  • Chapter 8: HIV/AIDS
  • Chapter 9: Ambulatory Care Records
  • Chapter 10: Long Term Care & Rehabilitation
  • Chapter 11: Hospice And Home Health Records
  • Chapter 12: Faxing
  • Chapter 13: Risk Management
  • Chapter 14: Record Retention and Destruction
  • Chapter 15: Electronic Health Information
  • Glossary of Terms

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