PHOTO COPYING MEDICAL RECORDS
PURPOSE:
To ensure continuity of care rendered to a veteran home resident at all
times.
DEFINITION:
A "Photo-copy" is a reproduction of an original record.
PROCEDURE:
Access to Medical Records will be by appointment only, free of charge.
The following list of steps should be followed when photo-copying
Medical Records.
A. Whenever possible, authorized internal users will be encouraged to
use the original health record rather than to obtain a facsimile.
B. All photo-copying of Medical Records will be done by the Medical
Record Technician or designee.
C. A Medical Information Release Form must be signed by the competent
resident or their appropriate responsible party (legal guardian) when
applicable.
D. Photocopies will be processed within 48 hours of written request (two
(2) business days excluding weekends and holidays). Should a delay
occur, written notification regarding same and expected completion must
be sent to the resident/representative.
E. Only specific requested forms shall be copied and sent to the
requestor, unless the information is being sent to a facility where the
resident is being permanently transferred. In that case, an abstract,
pertinent portions of the record that summarize important aspects of
resident care, is to be copied and sent to the requestor. The following
list of items constitute an abstract:
Admission Record
Discharge
Summaries form all Departments
Initial
Assessments from all Departments
History and
Physicals
Medical Plan of
Care
Physician Orders
Physician
Progress Notes
Nursing Monthly
Summaries
Social Service
History and Progress Notes
Dietary Progress
Notes
Activities
Progress Notes
Therapy Progress
Notes (PT, OT, etc.)
Consultant
Reports
Medication and
Treatment Records
Lab, X-ray, EKG
slips/reports
F. When photo-copies or other reproductions of Medical Records are
provided to authorized external users, these copies will be accompanied
by a statement:
|
1. Prohibiting use of the information for any
other than the stated purpose. |
G. The following outlines the charge fee for all photo-static documents:
First through
tenth page - .75 per page
Eleventh through
twentieth page - .50 per page
Twenty-first and
above - .25 per page
Revised: November 1994
MEDICAL RECORDS - 35-03-014