HIT 142- CH.11

Specialized Patient Records

mental health, substance abuse, home health, diseases, and genetic records.

Substance Abuse

Confidentiality:

No patient identification unless authorized with written consent through a proper release of information

Patient Notice: must be given with a list of rights when a patient enters the treatment program

release of information for substance abuse

needs to be a seperate release of information form

must be valid

must have notice of redisclosure

Specialized records release exception

Medical emergency

Research activities

Audit activities

To patient directly

Disclosures for Legal process

-Discovery and Subpoena requests do not authorize disclosure

-Court order does if it is valid

-Any legal requirements must follow established procedures for confidentiality.

-Litigation response plan

Disposition of Records

-patient consent needed

-confidentiality and privacy must be maintained

Mental Health and disability records

same as general health record but also include:

-more content(example: police interactions, work, legal events)

-stricter privacy

official record

record for mental health treatment that documents assessments, diagnoses, and interventions, ensuring confidentiality and compliance with privacy laws.

personal record

psychotherapy notes

notes kept by clinician

Mental Health and Disability record

privacy for Mental health and Disability

-no patient identification

-no release of information without consent

Home Health

-medical services provided at home for patients recovering from illness or injury

-CoP

Genetic Testing

GINA and HIPAA protect against discrimination

HIV and AIDS

confidentiality is required

Voluntary testing

patient has consented to test

Anonymous testing

allows individuals to get tested for conditions without disclosing their identity, ensuring privacy and confidentiality.

Mandatory Testing

a requirement for individuals to undergo testing for certain diseases, often for public health purposes or legal reasons.