A health record is created any time you see a health professional such as a doctor, nurse, dentist, chiropractor, or psychiatrist. You can find the following in information in your health record:
- Your medical history and your family’s medical history
- Labs and x-rays
- Medications prescribed
- Alcohol use and sexual activity
- Details about your lifestyle (smoking, exercise, recreational drug use, high-risk sports, stress levels)
- Doctor/nurse notes
- Results of operations and proceduresGenetic testing
- Research participation
- Driver’s License
- Social Security Number
This information is never used for commercial purposes. Its sole purpose is to keep the health professionals updated with your medical history. We will never share this information with anyone but your healthcare professionals.
According to the Department of Health:
HIPAA protects an individual’s health information and his/her demographic information. This is called “protected health information” or “PHI”. Information meets the definition of PHI if, even without the patient’s name, if you look at certain information and you can tell who the person is then it is PHI. The PHI can relate to past, present or future physical or mental health of the individual. PHI describes a disease, diagnosis, procedure, prognosis, or condition of the individual and can exist in any medium – files, voice mail, email, fax, or verbal communications.
HIPAA defines information as protected health information if it contains the following information about the patient, the patient’s household members, or the patient’s employers:
- Dates relating to a patient , i.e. birthdates, dates of medical treatment, admission and discharge dates, and dates of death
- Telephone numbers, addresses (including city, county, or zip code) fax numbers and other contact information
- Social Security numbers
- Medical records numbers
- Finger and voice prints
- Any other unique identifying number
South Omaha Medical Associates, Inc. (SOMA) recognizes that patients have rights which are essential to the dignity of life. SOMA also expects certain responsibilities from patients and friends to facilitate the provision of safe, quality health care. The following patient rights shall be provided to patients, family, and friends. -Drs. Correa
Respect and Dignity
- Patient has the right to care that respects his or her personal values and beliefs and to be treated with dignity and all times.
- Considerations of privacy in facility designs, direct patient interface and information controls create a patient environment that provides for the personal privacy of patients.
- Patient records, care discussion, consultation, examination, and treatment are considered confidential and utmost discretion is used with private information.
- Effective communication as illustrated by each patient having an identified attending physician and by each patient/family receiving complete explanations regarding procedures and treatment are utilized to facility patient understanding.
- Patients have the right to participate in the consideration of ethical issues that arise out of the provision of their care, including resolution of conflict, withholding of resuscitative services, forgoing or withdrawal of life sustaining treatment and participation of investigational studies and/or clinical trials. They also have a right to designate a representative decision maker in the event that they are unable to communicate their wishes regarding care.
- The patient and/or family are provided with appropriate education and training to enhance knowledge of the patient’s illness and treatment needs and to learn and demonstrate skills and behaviors that promote recovery and improve function.
- Available and medically indicated patient care and treatment services are provided to all patients on an equal basis without differentiation or consideration solely on the basis of medical condition, race, color, creed, national origin, disability or source of payment.
- The patient has the right to expect reasonable safety regarding office practices and environment
- The patient shall be reasonably informed by the physician in the decision involving their healthcare. To the degree possible, this should be clear, concise explanations of the patient’s condition, all proposed procedures, inherent risks of mortality or side effects, recuperation problems and probability of success. The patient shall not be subject to any procedure without voluntary, competent and understanding consent.
- The patient has the right to access Protective Services. SOMA will assist in determining the patient’s need for special services.
Refusal of Treatment
- At any time a patient can refuse treatment to the extent permitted by the law. Treatment refusal may constitute termination of the patient relationship.
Transfer and Continuum of Care
- To ensure the continuity of care, appropriate patient information is communicated to any healthcare organization or provider to/from which the patient is admitted, referred, transferred, or discharged. Relevant patient information can involve anything found in the patient’s medical file.
Office Rules and Regulations
- The patient shall be informed of office rules and regulations regarding their conduct and the conduct of their family and friends while on clinic premises.
South Omaha Medical Associates, Inc. (SOMA) recognizes that patients have rights which are essential to the dignity of life. SOMA also expects certain responsibilities from patients and friends to facilitate the provision of safe, quality health care. The following patient responsibilities shall be expected from patients, family, and friends. -Drs. Correa
Provision of Information
- The patient has the responsibility to provide, to the best of their knowledge, accurate and complete information about past illness, hospitalization, medications and other matters relating to their health. The patient has the responsibility to report unexpected changes in their condition to the responsible practitioner. The patient is responsible for indicating that they clearly understand the course of action considered and what is expected of them.
Compliance With Instructions
- The patient is responsible for following the treatment plan recommended by the attending physician. This may include following the instructions of nurses and allied health personnel as they carry out the coordinated plan of care, implement the attending physician’s orders, and enforce the applicable clinic rules and regulations. The patient is responsible for keeping appointments and, when unable to do so for any reason, for notifying the staff.
Refusal of Treatment
- The patient is responsible for their actions and consequences if they refuse treatment or do not follow the physician’s instructions.
- The patient is responsible for assuring that the financial obligations of their healthcare are fulfilled as promptly as possible. Insurance assignment does not relieve the patient from fulfilling financial obligations.
Office Rules and Regulations
- The patient is responsible for following office rules and regulations affecting patient care and conduct.
Respect and Consideration
- The patient is responsible for being considerate of the rights of other patients and office personnel and for assisting in the control of noise, smoking, and the number of visitors. The patient is responsible for being respectful of the property of other persons and of the office.
Successful patient visits require communication between the patient and the physician. A success implies that both the patient and physician were able to successfully develop a partnership and the patient has been fully educated in the nature of their condition (as well as the different methods on how to address the problem). This allows the patient to be more involved in the decision making process and establishes expectations and goals. We hope not only that patients can be honest with their health care providers but that they feel comfortable to be honest. We will never share patient information with a third party and will only use it to communicate information related to patient health.
An important part of maintaining communication is giving the medical clinic the proper forms of contact. We are best equipped when we have a patient’s:
- Home address
- Primary telephone number
- Social security number
- Email address
This enables us to make sure our patients can stay up to date with their health care and as healthy as possible! If you think your records are incomplete– please, feel free to call us today and we will help in any way possible.
We use Practice Fusion for the electronic management of our records system (EMR). This systems helps us comply with new federal regulations on digital charting and also allows us to better communicate with our patients.
[When patients] participate more actively in the process of medical care, we can create a new healthcare system with higher quality services, better outcomes, lower costs, fewer medical mistakes and happier, healthier patients
– Charles Safran, MD, President of AMIA
Our hope is that our patients are willing to participate in Practice Fusion by giving us their emails and being willing to communicate electronically. When we have all of the patients information we can then create an online patient portal. Online portals allow us to share the following information with our patients (safely, and privately!):
- Instantly share lab results, medications, diagnoses, care plans, immunization history, and more
- Provide free educational resources that help keep patients on their treatment plan
- Exchange secure messages with our patients to reduce phone use and increase ease of communication
- Patient portal is free your our practice and our patients, and only takes a brief moment to set up
We hope our patients see the value in participating with Practice Fusion’s patient portal and becoming part of our integrated system. The information found above, and much more, can be found at the Practice Fusion website.