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

• Clinical record reviews to ensure services are appropriate based on diagnosis, and the treatment plan is based on the Individual’s needs and progress notes support the use of each service.

• Clinical record content, screening, intake and assessment, documentation(a) The facility shall complete a face-to face screening with each individual to determine appropriateness of admission in accordance with 450:27-7-2.

• Clinical record documentation cannot include any references, inferences or indications of CRT procedures or strategies.

• Clinical record review of encounter data was performed to validate data sent to the State and confirm the findings of the analysis of the State-level data.Table A-4 summarizes results of Qualis Health’s EDV.

• Clinical record keeping systemEach CBSCC shall maintain an organized clinical record keeping system to collect and document information appropriate to the treatment processes.

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 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).

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.