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.

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Clinical record means the medical, dental, or mental health records of a client or member.

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.

Examples of Clinical record in a sentence

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

• If you have an Oregon insurance policy with the state law requirement that by accepting policy benefits, you are deemed to have consented to examination of your Clinical record for purposes of utilization review, quality assurance and peer review by the insurance company, then I may provide clinical information to your insurer for such purposes.

• For this reason I recommend that you allow me to provide you with a treatment summary instead, or in the case that you wish to review your entire Clinical record, that you do so in my presence or in the presence of another mental health professional, so that you can discuss the contents.

• While insurance companies can request and receive a copy of your Clinical record, they cannot receive a copy of your Psychotherapy Notes without your signed, written Authorization.

• Your Clinical record includes information about your reasons for seeking therapy, a description of the ways in which the problem impacts your life, your diagnosis, the goals that we set for treatment, your progress on those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of professional consultations, your billing records, and any reports that have been sent to anyone, including your insurance carrier.

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

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 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 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.