Clinical record definition

Clinical record means a legible electronic or hard-copy history that documents the criteria established for medical records as set forth in rule 441—79.3(249A). A claim form or billing statement does not constitute a clinical record.
Clinical record means either a paper, or electronic file, or both that is maintained by the behavioral health agency and contains pertinent psychological, medical, and clinical information for each individual served.
Clinical record means the medical, dental, or mental health records of a client or member.

Examples of Clinical record in a sentence

  • Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record.

  • These Psychotherapy Notes are kept separate from your Clinical Record.

  • I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information).

  • They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record.

  • PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in your Clinical Record.


More Definitions of Clinical record

Clinical record means a clinical record maintained in accordance with the Bylaws of the College of Physicians and Surgeons of British Columbia and an adequate medical record in accordance with the Medical Services Commission Payment Schedule.
Clinical record means all parts of the record required to be maintained and includes all medical records, progress notes, charts, and admission and discharge data, and all other information recorded by a facility which pertains to the patient’s hospitalization or treatment.
Clinical record means a written account which covers the services the agency provides directly and those provided through arrangements with another agency which account contains pertinent past and current medical, nursing, social, and other therapeutic information, including the plan of treatment.
Clinical record means a paper or electronic file that is main- tained by the provider and contains pertinent psychological, medical, and clinical information for each person served.
Clinical record means all parts of the record required to be maintained that are provided to an individual and includes all clinical records, assessments, financial and legal agreements and consents, progress notes, charts, admission and discharge data, clinical services, clinical summaries, individual therapy notes, group therapy notes, family therapy notes, and other information recorded by the facility staff, which pertains to the individual’s treatment.
Clinical record means the record that includes all the information and entries reflecting each resident's course of stay in an adult care home.
Clinical record means a tangible and legible record which meets the criteria established for clini- cal records set forth in rule 441—185.10(234).