Designated record set

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A designated record set is a record that contains protected health information maintained by or for a covered entity.

Introduction

The concept of designated record set was introduced by the Health Insurance Portability and Accountability Act (HIPAA). Failure to maintain complete, accurate, and current records can have severe adverse effect for a defendant in civil litigation. The designated record set is the record that would be released on a basis of a request for a record.

Minimum information

The primary purpose of HIPAA privacy regulation is to protect the privacy of individually identifiable information. Thus, HIPAA also states that the minimum necessary, that is the minimum amount of data necessary to accomplish a request for information, should be released. This record set will vary on the basis of the requestor and the requestor’s rights and needs.

Facilities typically define medical record documentation and billing documentation components of their designated record sets. The designated record set medical record usually includes, history of current illness, physician orders to admit and to treat, diagnostic and therapeutic orders, diagnostic test results, lab, radiology results that were reported during the course of care, consultation reports, daily progress notes, nursing documentation of care, and discharge summary and discharge instructions. The billing subset typically includes, payment, claims adjudication, health care enrollment related information.

Notably, the definition still carries in its name the archaic, chart driven concept of how documentation is maintained at a health care facility. Since hybrid record status is a reality for many of those, ideally, the institutional policies will define and determine the best sources for assembling specific health data into their designated record sets.

Submitted by (Judit Olah)