Medical Records Law and Legal Definition
Every time a patient receives healthcare, a record is maintained of the observations, medical or surgical interventions, and treatment outcomes. This record includes information that the patient provides concerning his or her symptoms and medical history, the results of examinations, reports of x rays and laboratory tests, diagnoses, and treatment plans. Medical records and health information technicians organize and evaluate these records for completeness and accuracy.
The main federal law regulating health information us the Privacy Rule under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), which came into effect in April 2003. The Security Rule, also required under HIPAA, was issued in final form on February 20, 2003 and will become effective in 2005.
The HIPAA Privacy Rule defines protected health information (PHI) very broadly. PHI includes individually identifiable health information related to the past, present or future physical or mental health or condition, the provision of health care to an individual, or the past, present, or future payment for the provision of health care to an individual. Even the fact that an individual received medical care is protected information under the regulation.
The Privacy Rule establishes a federal mandate for individual rights in health information, imposes restrictions on uses and disclosures of individually identifiable health information, and provides for civil and criminal penalties for violations. The complementary Security Rule includes standards for protection of health information in electronic form.
Legal Definition list
- Medical Practice Facility [Banks & Banking]
- Medical Practice
- Medical Peer Review
- Medical Payment Insurance
- Medical Parole
- Medical Records
- Medical Research [Internal Revenue]
- Medical Review Officer (MRO)
- Medical Savings Account (MSA)
- Medical Savings Account Plan (MSA Plan)
- Medical Services [Employee Compensation]
Related Legal Terms
- Acceptable Medical Source
- Aeromedical Evacuation
- Agency Records [Aeronautics and Space]
- Agency Records [Recovery Accountability and Transparency Board]
- Allowable Medical Expenses
- American Board of Medical Specialties (ABMS)
- Approved Medical Residency Training Program
- Authority to Request Records for a Law Enforcement Purpose
- Authorized Medical Physicist
- Board of Medical Examiners
