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
Chapter 2: General Release of Information
Chapter 3: Authorizations
Chapter 4: Required Disclosure Statements
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)
- Related Link
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
Chapter 8: HIV/AIDS
Chapter 9: Ambulatory Care Records
Chapter 10: Long Term Care & Rehabilitation
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
Chapter 13: Risk Management
Chapter 14: Record Retention and Destruction
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 Date: July 1, 2018