Policy 1110: Designated Record Sets
YAKIMA COUNTY FIRE DISTRICT 12
10000 ZIER ROAD
YAKIMA, WA 98908
POLICY # 1110
COMMISSION CHAIR SIGNATURE: s/b Ken Eakin, Chair
EFFECTIVE DATE: 03/01/05
REVISED DATE: 06/10/08
POLICY TITLE: DESIGNATED RECORD SETS
1.0 PURPOSE
1.1 To insure that Yakima County Fire District 12 releases Protected Health information (PHI) in accordance with the Privacy Rule. This Policy establishes a definition of what information should be accessible to patients as part of the Designated Records Sets (DRS), and outlines procedures for requests for patient access, amendment and restriction on the use of PHI.
1.2 Under the Privacy Rule, the DRS include medical records that are created or used by the District to make decisions about the patient.
2.0 DIVISIONS AFFECTED
All divisions.
3.0 REFERENCES
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
4.0 POLICY
The DRS should only include HIPAA covered PHI, and should not include information used for the operational purposes of the organization, such as quality assurance data, accident reports, and incident reports. The type of information that should be included in the DRS is medical records and billings records.
5.0 PROCEDURE
The DRS for any requests for access to PHI includes the following records:
5.1 The Medical Incident Report (MIR) created by EMS field personnel (this includes any photographs, monitor strips, Physician Certification Statements, Refusal of Care forms, or other source data that is incorporated and / or attached to the MIR.
5.2 The electronic claims records or other paper records of submission.
5.3 Amendments to PHI, or statements of disagreement by the patient requesting the amendment when PHI is not amended upon request, or an accurate summary of the statement of disagreement.
5.4 DRS also includes copies of records created by other service providers and other health care providers such as first responder units, assisting ambulance services, air medical services, nursing homes, hospitals, police departments, coroner’s office, etc., that are used by the District as part of treatment related to the patient.