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Hipaa Medical Records Question

  1. Default Hipaa Medical Records Question
    Medical Coding Books
    We are and OBGYN office with a contracted ultrasound technician team who performs our ultrasounds. It has been an office policy of ours that we do not release copies of the ultrasound pictures, only the reports when sending medical records. Is this a violation?
    Also, we don't include billing information, registration/insurance information nor medical records received from any entity that we did not refer the patient to. Is this a violation?

    Thank you kindly!

  2. Default
    I think it depends on what you define your legal record as. If the pictures are part of the legal record, then they should be released.

    As far as billing information/insurance etc - if is is a request for continued care, then I would say you don't need to release that type of information asit does not add anything to the clinical picture. If it is for legal reasons then, you should be releasing it because they are probably considered part of your legal record.

    As far as records received from other entities - if they are used in medical decision making then they should be included in the release. Basically how can you tell which were used and which were not - so I would release. They are part of your record.

    Janet Mohlenhoff, RHIA, CCS

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