03-Designated Record Set

Approved by: William Voss	Effective: April 1, 2024
Review: Annual	Revised:
Renewed By:	Renewed:

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Designated Record Set

Policy Statement

River City TMS, PLLC maintains a Designated Record Set (DRS), which contains the medical and billing records that are included within patient’s rights to access. The DRS is maintained in Paper and Electronic format(s). The included records contain basic information, such as demographics, assessments, diagnosis, billing claims data, as well as medically observed or inferred information that is used to make decisions about the individual’s care.

The Designated Record Set is legally defined as a set of information maintained by or for a covered entity that consists of medical and billing records about individuals maintained by, or for, a covered health care provider and, in whole or in part, by or for, the covered entity’s use when making decisions about individuals. Information contained in the DRS comprises the entirety of the medical record information that a patient can request to access, amend, or have sent to a third party.

Procedure

• Electronic Medical Records

  The DRS for River City TMS, PLLC is the Electronic Medical Records (EMR)/Electronic Health Records (HER) system.

• Records from Other Providers §164.524(e)(1)

  Copies of records from other healthcare providers are included in the DRS. River City TMS, PLLC will ensure that their patients have access to all medical records that are used to make decisions about their care, thus any medical information that is captured by referred and prior physicians will be included in the DRS. When these records are not readily handed over from other providers, patients will be asked to confirm whether the information received is accurate. Any requests for amendment to this information will be evaluated and addressed with the provider who sent the information.

• Identification of Information Not Considered Part of DRS §164.524(d)(3)

  It is important that any information in the medical record that is not considered part of the DRS is identified. This is information the patient will not have a right to access or amend.

  Paper records that are not considered part of the DRS will be by name.

  Electronic records that are not considered part of the DRS will be .

• Medical Information Considered for DRS §164.524(e)(1)

  When determining which information is considered part of the DRS, medical information maintained in all types of media (paper, oral, video, electronic, film, digital) is considered if the information is created and/or maintained for the purpose of making decisions about patients.

  The following types of medical information are included and/or excluded in the DRS:

  Included

  Excluded
  400 S Jefferson Street, Spokane WA 99204