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Understanding Your Health Record/Information
Each time you visit a nursing agency, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnosis, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:
→ basis for planning your care and treatment;
→ means of communication among the many health professionals who contribute to your care;
→ legal document describing the care you received;
→ means by which you or a third-party payer can verify that services were actually provided;
→ a tool in educating health professionals;
→ a source of data for medical research;
→ a source of information for public health officials who oversee the delivery of health care in the United States;
→ a source of data for agency planning and marketing; and
→ a tool with which we can access and continually work to improve the care we render and the
outcomes we achieve.
Understanding what is in your record and how your health information is used helps you to ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others.
How We Will Use or Disclose Your Health Information
1) Treatment. We will use or disclose your health information for treatment purposes, including for the treatment activities of other health care providers. For example, information obtained by a nurse, physician, or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment. We will also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you are discharged from the nursing agency.
2) Payment. We will disclose your health information for payment, including for the payment activities of other health care providers or payers. For example, a bill may be sent to you or a third-party payer, including Medicare or Medicaid. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.
3) Health care operations. We will disclose your health information for our regular health operations. For example, members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to access the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the health care and service we provide.
In addition, we will disclose your health information for certain health care operations of other entities. However, we will only disclose your information under the following conditions: (a)
the other entity must have, or have had in the past, a relationship with you; (b) the health information used or disclosed must relate to that other entity’s relationship with you; and (c) the disclosure must only be for one of the following purposes: (i) quality assessment and improvement
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