What counts as medical information?
Asked by: Assunta Heller III | Last update: October 13, 2025Score: 5/5 (19 votes)
What constitutes medical information?
"Individually identifiable health information" is information, including demographic data, that relates to: the individual's past, present or future physical or mental health or condition, the provision of health care to the individual, or.
What is not considered medical information?
However, “medical information” does not include a consumer's age or sex, or demographic information such as a consumer's residence or e-mail address, or any other information “that does not relate to the physical, mental, or behavioral health or condition of a consumer, including the existence or value of any insurance ...
What should be included in medical information?
A personal health history (conditions, how they're being treated and how well they're controlled, as well as important past information such as surgeries, accidents and hospitalizations) Doctor visit summaries and notes. Hospital discharge summaries. Pharmacy printouts that accompanied prescribed medications.
What counts as a medical statement?
Medical source statements can include information such as: Your diagnosis. The results of diagnostic testing, including physical exams, radiology scans, and lab tests. Treatments you have undergone for your condition, including surgeries or physical therapy.
The Right to Access and Correct Your Health Information
What counts as a medical document?
A health record (also known as a medical record) is a written account of a person's health history. It includes medications, treatments, tests, immunizations, and notes from visits to a health care provider.
What counts as a medical term?
Medical terminology refers to the words and language used specifically in the medical and health fields. The proper definition describes medical terminology as language used to describe anatomical structures, procedures, conditions, processes and treatments in the medical field.
What is not considered part of the medical record?
The law describes certain types of information which are not considered to be a part of the medical record, e.g., any aggregate information about several patients, information regarding any other patient, and certain information which may have been provided in confidence by someone other than the patient, or any other ...
What is a good source of medical information?
Medline Plus | medlineplus.gov
The best “first stop” for consumer health information from the National Library of Medicine and the National Institute of Health.
What is information in medical?
Medical Information (MI) is the collection, handling and dissemination of information on medications, and their safe and correct use. The MI department or function is the primary interface between the Marketing Authorisation Holder and the patient/consumer or healthcare professional.
What is non-medical information?
Non-medical evidence is simply defined as any evidence that is not medical. Submitting non-medical evidence in your disability claim helps present a more complete picture of how your impairments and symptoms affect your daily functioning.
What is not considered personal health information?
What is not considered PHI? Identifying information, such as personal names, residential addresses, or phone numbers, is not considered PHI unless it is related to health data. For instance, names, addresses, and phone numbers listed in a phone book is not considered PHI because it is not related to heath data.
What is an incomplete medical information?
Incomplete documentation can lead to misdiagnoses, inappropriate medication prescriptions, and gaps in patient care, ultimately resulting in adverse health outcomes. The stakes are incredibly high and the figures associated with medical errors due to inadequate information are staggering.
Which is not considered medical information?
When a medical record has all identifiers removed, such as names, phone numbers, serial numbers, and physical addresses, it's not considered PHI. Covered entities and business associates can share these unidentified records under HIPAA.
What are three things you should not add to a medical record?
- Financial or health insurance information,
- Subjective opinions,
- Speculations,
- Blame of others or self-doubt,
- Legal information such as narratives provided to your professional liability carrier or correspondence with your defense attorney,
What information is included in a medical history?
A record of information about a person's health. A personal medical history may include information about allergies, illnesses, surgeries, immunizations, and results of physical exams and tests.
How to find medical information?
Medical and health care organizations, hospitals, and academic medical institutions may also be reliable sources of health information. Your health care provider can also suggest ideal sources of online information. If your doctor's office has a website, it may include a list of recommended links.
Is medical advice the same as medical information?
Typically, medical advice involves giving a diagnosis and/or prescribing a treatment for medical condition. Medical advice can be distinguished from medical information, which is the relation of facts. Discussing facts and information is considered a fundamental free speech right and is not considered medical advice.
Can I ask a doctor a question online for free?
Fortunately, we can now utilize our technological advances to our advantage when it comes to our health! SmartDocMD makes it easy for you to ask a doctor online free about what's going on, so that you can get what you need, when you need it.
What counts as a medical record?
The traditional medical record for inpatient care can include admission notes, on-service notes, progress notes (SOAP notes), preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes.
What information can be shared without violating HIPAA?
HIPAA permits health care providers to disclose to other health providers any protected health information (PHI) contained in the medical record about an individual for treatment, case management, and coordination of care and, with few exceptions, treats mental health information the same as other health information.
Are emails part of a medical record?
E-mail exchanges constitute a form of progress note. Unless the provider is using an electronic patient record that allows the inclusion of e-mail messages, each e-mail message should be printed in full and a copy placed in the patient's paper record.
What is included in medical terms?
All medical terms have a root word. They may also have a prefix, a suffix, or both a prefix and a suffix. Prefixes have a droppable "o", which acts to connect the prefix to root words which begin with a consonant.
What is considered long term medical?
Long-term care (also called “custodial care” or “long-term services and support”) includes medical and non-medical care for people who have a chronic illness or disability. This may include: Personal care assistance (like help with everyday activities, including dressing, bathing, and using the bathroom)
Which word is always found in a medical term?
Medical terms always have at least word root. The root provides the core meaning of the term.