Demographics Patient Identification Numbers or Cards (SS#, Medical Record Number, Drivers License)...
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Demographics Patient Identification Numbers or Cards (SS#, Medical Record Number, Drivers License) Full Name Street Address City, State, Zip Code Phone Number Fax Number E-mail address URLs and IP Addresses Gender Race Religion Date of Birth Photographs Spouse Information Beneficiary Information Parent/Guardian Information Emergency Contact Information Vehicle Identification Number Biometric Identifiers (including finger and voice prints) Insurance Information Financial Information Insurance Carrier Insurance Group Numbers Copy of Insurance Card Guarantor (Responsible Party) Billing Address Employer Primary Care Provider Total Charges Claim Forms Payment History Pre-certifications or Prior Authorizations Example of Medical Record Elements Medical Information (continued) Procedures Orders or Requests Patient History Personal Habits Weight Height Age Temperature Pulse History of Present Illnes Dictation Symptoms Physical Findings Family Medical History Discharge Status Medications Barriers to Communication Mode of Arrival Allergies/Untoward Reactions to Drugs Reason for Encounter Request for Consultation CPT Codes ICD-9 Codes Date of Death Medical Information Patient Complaints Dates of Service Admission and Discharge Dates Treating or Referring Physician, Clinic, Hospital Diagnosis Treatment Plan Immunization Record Psychotherapy Note Information Lab Tests Blood Type
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Transcript of Demographics Patient Identification Numbers or Cards (SS#, Medical Record Number, Drivers License)...
DemographicsPatient Identification Numbers or Cards (SS#, Medical Record Number, Drivers License)Full NameStreet AddressCity, State, Zip CodePhone NumberFax NumberE-mail addressURLs and IP AddressesGenderRaceReligionDate of BirthPhotographsSpouse InformationBeneficiary InformationParent/Guardian InformationEmergency Contact InformationVehicle Identification NumberBiometric Identifiers (including finger and voice prints)
Insurance InformationFinancial InformationInsurance CarrierInsurance Group NumbersCopy of Insurance CardGuarantor (Responsible Party)Billing AddressEmployerPrimary Care ProviderTotal ChargesClaim FormsPayment HistoryPre-certifications or Prior Authorizations
Example of Medical Record Elements
Medical Information (continued)ProceduresOrders or RequestsPatient HistoryPersonal HabitsWeightHeightAgeTemperaturePulseHistory of Present IllnessDictationSymptomsPhysical FindingsFamily Medical HistoryDischarge StatusMedicationsBarriers to CommunicationMode of ArrivalAllergies/Untoward Reactions to DrugsReason for EncounterRequest for ConsultationCPT CodesICD-9 CodesDate of Death
Medical InformationPatient ComplaintsDates of ServiceAdmission and Discharge DatesTreating or Referring Physician, Clinic, HospitalDiagnosisTreatment PlanImmunization RecordPsychotherapy Note InformationLab TestsBlood Type
DemographicsPatient Identification Numbers or Cards (SS#, Medical Record Number, Drivers License)Full NameStreet AddressCity, State, Zip CodePhone NumberFax NumberE-mail addressURLs and IP AddressesGenderRaceReligionDate of BirthPhotographsSpouse InformationBeneficiary InformationParent/Guardian InformationEmergency Contact InformationVehicle Identification NumberBiometric Identifiers (including finger and voice prints)
Insurance InformationFinancial InformationInsurance CarrierInsurance Group NumbersCopy of Insurance CardGuarantor (Responsible Party)Billing AddressEmployerPrimary Care ProviderTotal ChargesClaim FormsPayment HistoryPre-certifications or Prior Authorizations
Limited Data Set
Medical Information (continued)ProceduresOrders or RequestsPatient HistoryPersonal HabitsWeightHeightAgeTemperaturePulseHistory of Present IllnessDictationSymptomsPhysical FindingsFamily Medical HistoryDischarge StatusMedicationsBarriers to CommunicationMode of ArrivalAllergies/Untoward Reactions to DrugsReason for EncounterRequest for ConsultationCPT CodesICD-9 CodesDate of Death
Medical InformationPatient ComplaintsDates of ServiceAdmission and Discharge DatesTreating or Referring Physician, Clinic, HospitalDiagnosisTreatment PlanImmunization RecordPsychotherapy Note InformationLab TestsBlood Type
*Provided no name, patient identifier numbers, group numbers or other specific identifiers are included (i.e., "facial identifiers").
DemographicsPatient Identification Numbers or Cards (SS#, Medical Record Number, Drivers License)Full NameStreet AddressCity, State, Zip CodePhone NumberFax NumberE-mail addressURLs and IP AddressesGenderRaceReligionDate of BirthPhotographsSpouse InformationBeneficiary InformationParent/Guardian InformationEmergency Contact InformationVehicle Identification NumberBiometric Identifiers (including finger and voice prints)
Insurance InformationFinancial InformationInsurance CarrierInsurance Group NumbersCopy of Insurance CardGuarantor (Responsible Party)Billing AddressEmployerPrimary Care ProviderTotal ChargesClaim FormsPayment HistoryPre-certifications or Prior Authorizations
DE-IDENTIFIED DATA
Medical Information (continued)ProceduresOrders or RequestsPatient HistoryPersonal HabitsWeightHeightAgeTemperaturePulseHistory of Present IllnessDictationSymptomsPhysical FindingsFamily Medical HistoryDischarge StatusMedicationsBarriers to CommunicationMode of ArrivalAllergies/Untoward Reactions to DrugsReason for EncounterRequest for ConsultationCPT CodesICD-9 CodesDate of Death
*Medical InformationPatient ComplaintsDates of ServiceAdmission and Discharge DatesTreating or Referring Physician, Clinic, HospitalDiagnosisTreatment PlanImmunization RecordPsychotherapy Note InformationLab TestsBlood Type
*No individually identifiable health information included.
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