Section 29: Medical Record and Media
The Callier Center must ensure a single unit medical record is comprised of all appropriate medical data generated on each individual Callier Center patient for continuity of patient care and legal purposes. Any copies made of medical records for convenience (Case Management Records/Shadow Records) or any other copies made for a health care operation of the Center must be tracked and secured just as if these copies were the official medical record (OMR).
The Center maintains an OMR for each patient. The OMR is maintained in the Center’s Medical Records Department (MRD). All records maintained by or for the Center, including the OMR, Medical Media and Shadow Medical Records (SMR), must be maintained confidentially as required by HIPAA. Departments, divisions and individual workforce members are not permitted to create or maintain record sets on behalf of the Center outside of the OMR; however, health care providers or departments may retain shadow medical records as convenience copies only. SMR must be maintained confidentially and securely at all times and destroyed in accordance with UT Dallas policy when no longer necessary. SMR are not considered to be part of the Center’s designated record set.
The HIPAA Privacy Officer retains the right at all times to audit workforce member’s retention and or use of SMR to ensure compliance with the policy manual.
Medical Media that constitutes part of a patient’s OMR is considered part of the patient’s designated record set. Any Medical Media that cannot be filed in the electronic medical records system must be documented by the Medical Records Administrator as part of the OMR and the documentation must be maintained in the OMR.
Medical Media not in active use by a workforce member must be maintained in the MRD. Medical Media which is capable of transformation into a format that can be filed into the electronic medical records system must be securely destroyed after the information contained in the media has been entered into the electronic medical records system.
HIPAA Regulatory Citation: 45 CFR § 164.530 Effective: 04/14/2003
Reviewed: 03/30/2021, 12/08/2015
Donise W. Pearson, HIPAA Privacy Officer
UT Dallas Callier Center