Medical Information fields

Sensitive Data

Sensitive Data refers to:

o       Substance abuse;

o       Psychiatric / psychological care;

o       HIV / AIDS diagnosis or treatment.

When this checkbox is selected, the captured medical records will be reviewed by Ciox Health specialists who verify that:

o       every page is associated with the specified patient;

o       the requester was properly identified;

o       the request included an authorization for sensitive information.

This checkbox is not available for Onsite Delivery requests, since the Medical Records are provided to the requester before they can be reviewed.

AOD Tracking

A disclosure is a release, transfer, access to, or divulging of information outside of the covered entity. Select this box if fulfilling the request would result in the disclosure of a patient’s health information for reasons other than treatment, payment, or health care operations or if the disclosure was not specifically authorized by the patient.

Years Searched

Only appears during Fulfillment.

In some situations, Florida law requires that we capture how many years were searched to locate the requested medical records.

The Years Searched field does not appear when fulfilling requests at sites located in states or territories other than Florida.

Date Ranges

At least one Date Range must be defined for every request. A maximum of 10 Date Ranges can be included in any single request.

You can add and remove Date Ranges in Fulfillment.

Allowed Date Range values

The rules for acceptable Date Range values depend on the status of the request:

o       Logging — “real” From and To dates or “fuzzy” choices, marked with an asterisk * below.

o       Fulfillment — real From and To dates required.

Date Ranges and Pull Lists

Date Range fields do not appear on the Request screen when working on a Pull List.

Dates of Service (DOS) are defined for each patient on the Pull List screen, which appears as part of the Logging process.

You can add Date Ranges to a Pull List “child” request during Fulfillment.

From

Date field

The “start” date for collecting the requested Medical Records.

Any & All *

All available records should be collected.

Fulfiller Review *

The From date cannot be determined during Logging. It may be necessary to view the Medical Records to decide the correct date.

Most Recent Visit *

The Request Letter does not specify actual dates.

The available Medical Records must be compared to the Request Letter Date to decide which records should be retrieved.

Months prior to Request Letter Date

Automatically calculates the From date by counting “backwards” from the Request Letter Date.

To

Date field

The "end" date for collecting the requested Medical Records.

Fulfillment Date

Automatically fills the To field with the date on which the request is submitted from Fulfillment.

When you choose this option, the To date will appear to be blank when you Submit the request from Fulfillment, but the calculated date will be part of the request and be visible if you open it later.

Facility Received Date

Automatically fills the To field with the Facility Received Date.

Request Letter Date

Automatically fills the To field with the Request Letter Date.

Other Date Range commands

Clear

The Clear link “resets” the Date Range values to empty.

If you have multiple Date Ranges, each one has a separate Clear link.

Delete

You can Delete a Date Range in Logging or Fulfillment, as long as one Date Range remains.

Record Sets

If a Record Set is associated with the first Date Range, that set will also be associated with any additional Date Ranges for the request.

You cannot apply a different Record Set to a different Date Range in the same request.

You can add Record Types that are not in the Record Set to any of the Date Ranges.

Add New Date Range

Click this link to create a blank Date Range, with all the same data entry fields described above.

If a Record Set is associated with the first Date Range, that set will also be associated with any additional Date Ranges for the request.

A request can have as many as 20 Date Ranges.

Record Type fields

Requested

Checkmarks show which of the listed Record Types need to be retrieved.

If a Record Set was applied to the request, all the Record Types in the set will be flagged as Requested. You cannot clear any of these selections or mark them as not requested.

Record Types

Name of the Record Types associated with the request.

During Logging, the "contents" of Record Sets are not automatically displayed. Click Show to see the Record Types in the set.

If a Record Set has been applied to a request, all the Record Type names are displayed when you open the request for Fulfillment.  

Retrieved

Only appears during Fulfillment.

At least one Record Type must be marked as Retrieved before you can Submit the request from Fulfillment.

Add Record Type

Type the name of the requested document in this field and press ENTER to add it to the request.

If a Record Set has been applied to the request, you can still add Record Types that are not part of the set.

Chart Location

Chart Location

These fields let you specify how and/or where the facility stored the Medical Records for a request.

They are not displayed during Logging.

There are six Chart Location choices. Multiple choices are allowed.

o       EMR

o       Film / Fiche (microfilm / microfiche)

o       Internal Clinic / Department

o       Off Site Clinic

o       Off Site Storage

o       Paper

The Request Details report includes a Chart Location column

Indicate Reasons for Records Not Retrieved

IF at least one requested Record Type is not marked as Retrieved in Fulfillment, THEN you can select one or more of the Indicate Reasons for Records Not Retrieved choices.

You are not technically required to select one of these choices when one or more Record Types was not retrieved. If at least one Record Type is Retrieved, you can Submit the request from Fulfillment.

Information Not Available

Specific requested records could not be found.

Not Authorized

Request Letter does not provide enough authorization.

Records Not Retrieved by Datavant

Ciox does not service the location / provider at which the records are located.

Comment

Any additional information about why the records could not be collected.

Medical Records Page Counts

These fields indicate the source of the retrieved Record Types, as automatically determined by HealthSource Clarity.

You can manually change these values, as long as the individual numbers add up to the correct Total Pages.

Electronic

Files attached to the request or printed to the request through SecureCapture.

Paper

Pages scanned directly into the request.

If you scanned the pages to your computer or a network location and then attached them, the pages will be counted as Electronic.

Microfilm

Original documents stored as microfilm.

Total Pages

Sum of the other three fields.