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GUIDANCE (Jan. 2007)

DESIGNATED RECORD SET PROCESS

HIPAA regulations state that patients have a right to access portions of their medical record, which is called the "Designated Record Set."  The Designated Record Set ONLY applies when the requested medical information is RELEASED TO THE PATIENT/DESIGNEE and/or when the patient/designee requests an amendment.

What is included in the Designated Record Set (DRS)?
  1. Official Medical Record - UCMC, RDO
  2. Billing Records - UCMC, RDO, and UCPG
  3. Outpatient Dialysis records (inpatient records are part of the official Medical Record)
  4. Shadow File

What if the patient is requesting information be released to another entity (e.g. attorney, insurance company, school)?

Direct the patient or patient's representative to Outpatient Services in 1A or 2B in the DCAM to complete the authorization form.


What do I do when a patient requests access to their DRS?
  1. If the patient is ONLY asking for small volume treatment request up to a "mini-chart," the coordinator or health care provider will release the information requested and give it directly to the patient or patient's representative.  If the patient is seeking lab results directly from the lab, the lab may decline under CLIA.  If the patient is seeking psychiatric records, see Administrative policy 05-14(B) and 02-10.
  2. If the patient is asking for anything beyond small volume treatment requests, direct them to Outpatient Services in 1A or 2B in the DCAM.
  3. Outpatient Services will
    1. Ask them to complete the "Request and Authorization to Copy Health Information" form.
    2. Make sure the form is signed and dated
    3. Give them a copy of the form; maintain the original
    4. Place the form in the designated Medical Records "retrieval box"

Medical records personnel will retrieve the forms at least daily and do the following:
  1. Log the request into their database
  2. Fax the form to other entities, as indicated:
    1. UCMC
    2. Regional Doctors Offices
    3. UCMC Billing records
    4. Billing records for University of Chicago Physicians Group (UCPG) and Regional Doctors Offices (RDO)
    5. Other Specialty Areas with records kept outside of Medical Records (e.g. radiology films, pathology)

What will UCMC, Regional Doctors Offices, Billing Offices and the Specialty areas do with the faxed request?
  1. Log the request into their database
  2. Complete the patient's request within 30 days
  3. Indicate on the form the date and initials of the person that is completing the request for our records
  4. Database/summary must be available for internal auditing to ensure timely response to request

What is our timeframe to release medical record information to patients?
We must have the request completed within 30 days from the day the patient makes the written request.


What happens if the request occurs at an RDO and involves the medical record from UCH?
After the request is logged in database, a fax should be sent to UCMC Medical Records where they will:
  1. Log the request into their database
  2. Complete the patient's request within 30 days
  3. Indicate on the form the date and initials of the person that is completing the request for our records
  4. Database/summary must be available for internal auditing to ensure timely response to request
ORIGINAL REQUEST FORM SHOULD REMAIN IN THE MEDICAL RECORD AT POINT OF RECORD REQUEST.


What if the patient is requesting information that is not included in the designated record set (e.g. Radiology films)?
Utilize the current procedures.


What if the request comes from an inpatient?
  1. Nursing staff will provide a "Request and Authorization to Copy Health Information" form upon discharge
  2. Nursing staff will assist the patient in completing the form, if they would like to make a request
  3. Patients will be directed to the Office of Admitting on the 2nd floor of the Bernard Mitchell lobby
  4. The requests will be retrieved at least daily by Medical Records
  5. Medical Records will log the request into their database
  6. Complete patient's request within 30 days
  7. Indicate the date and initials of person completing the request for records
  8. Database/summary must be available for internal auditing to ensure timely response to request
  9. See Administrative policy No. 02-02

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Call 4-9716 for more details.

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