The Medical Record

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The Medical Record:

MEDICAL BILLING HOME-STUDY COURSE

is a comprehensive program for those interested in a career in Medical Billing. This at-your-own- pace course covers every aspect imaginable!

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Medical Billing Training Software Included

What's In The Medical Record?

Medical records refer to records, either in paper or electronic form, of the results of medical tests, diagnoses and treatments for individuals. Anybody who ever set foot in a medical office and has been seen by a doctor has a patient file containing a medical record. The doctor routinely shares this medical record with other physicians and medical insurance companies.

Medical ethics dictate that revealing medical records for any purpose other than treatment and is a violation of patient-physician confidentiality. People who apply for certain kinds of life and health insurance may give the insurance company their permission to access it.

Efficient medical record keeping facilitates current and future medical treatment of individuals by recording which treatments have and which have not been effective, and the degree to which they have been effective as well as preventing harmful interactions attributable to different medical treatments.

What Information is in the Medical Record?

Aside from information about physical health a person's medical records may include information about family relationships, sexual behavior, substance abuse, and even the private thoughts and feelings that come with psychotherapy.

This information is often keyed to a social security number. Because of a lack of consistent privacy protection in the use of Social Security Numbers, the information may be easily accessible.

Information from your medical records may influence your credit, admission to educational institutions, and employment. It may also affect your ability to get health insurance, or the rates you pay for coverage (OTA report). More importantly, having others know intimate details about your life may mean a loss of dignity and autonomy. The Fair and Accurate Credit Transactions Act mandates that you can request a free copy of your medical report once a year.

Abuses

The outsourcing of medical record transcription and storage has the potential to violate patient-physician confidentiality by possibly allowing unaccountable persons access to patient data. Governments have often refused to disclose medical records of military personnel who have been used as experimental subjects.

Medical Record Privacy

Protect the privacy of their social security number

Tell their physician everything necessary for proper treatment, but “think twice before disclosing information that has no bearing on their health.” (Consumer Reports, Oct. 1994, p. 629)

Ask for a notification if their medical records are ever subpoenaed

Ask their doctor if any of the records can be accessed from outside the office. If so, they should ask for what purpose they may be accessed

Before the office sends their medical records to another party, such as an insurance company, they should ask to be allowed to review the record

Control access to other personal information

**Copyrights: All text on this page is available under the terms of Wikipedia's GNU Free Documentation License. Wikipedia is a web-based free content encyclopedia written collaboratively by volunteers and sponsored by the non-profit Wikimedia Foundation.

GroupOne Health Source: The Stimulus Bill is a golden opportunity for physicians to get paid to realize the full benefits of a modern EHR system. The American Recovery & Reinvestment Act was signed into law on February 17, 2009. The health IT component of the Bill, the HITECH Act, appropriates $19.2 billion dollars to encourage the adoption of electronic health records. The Stimulus Bill should help provide most physicians in the United States with an electronic health record system at ZERO net cost to the physician.

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