Gynecologist
In this presentation, the author will give an overview of the procurement and analysis of medical records required for a patient who needs to see a gynecologist for abnormal uterine bleeding at a gynecological office. This previously would have been purely a paper process, including the internal office process with regard to patient forms (information and release paperwork), the internal hospital facility process of form processing and finally the same process in the gynecologist's office. However, the rise of the Obama health care plan has mandated a transition to electronic records over the next five years, so this must be factored into the process now as well (Childs, Chang, & Grayson, 2009). Both electronic and paper records will however have the same basic features as listed below.
The patient has called the office requesting an appointment. The patient said that the gynecologist admitted her to the hospital, performed the surgery and said she should follow up with her own physician. This author needs to obtain the hospitalization medical records for this patient. In the following description is are the relevant components of the family physician will want to...
In the U.S. Department of Health & Human Services, the Office for Civil Rights of the enforces the HIPAA Privacy Rule. This protects the privacy of individually identifiable health information. The HIPAA Security Rule sets national standards for the security of electronically protected health information. The confidentiality provisions of the Patient Safety Rule protect identifiable information being used to analyze patient safety events and improve patient safety. All along the medical record procurement and deployment process, U.S. law demands absolute confidential handling of patient information and mandates strict safeguarding of that information. Release of that information without the patient's express consent is strictly forbidden ("Health information privacy," 2011).
Under HIPPA, a patient release form/letter will be…
