Md. Code Regs. 10.01.16.02 - Definitions

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

(1) "Divisible" means a medical record that is amenable to separation or division after the expiration of the retention time stated in Regulation .04 of this chapter.

(2) Health Care Provider.

(a) "Health care provider" means an acupuncturist, audiologist, chiropractor, dietician, dentist, electrologist, massage therapist, mortician, nurse, nutritionist, occupational therapist, optometrist, physical therapist, physician, podiatrist, professional counselor, psychologist, social worker, speech-language pathologist, or a health care facility or entity that is a:

(i) Freestanding, ambulatory care facility as defined in Health-General Article, § 19-3 B-01, Annotated Code of Maryland;

(ii) Freestanding medical facility as defined in Health-General Article, § 19-3 A-01, Annotated Code of Maryland;

(iii) Health maintenance organization as defined in Health-General Article, §19-701, Annotated Code of Maryland;

(iv) Hospital as defined in Health-General Article, §19-301, Annotated Code of Maryland;

(v) Limited service hospital as defined in Health-General Article, §19-301, Annotated Code of Maryland;

(vi) Related institution as defined in Health-General Article, §19-301, Annotated Code of Maryland;

(vii) Residential treatment center as defined in Health-General Article, §19-301, Annotated Code of Maryland; and

(viii) Health care facility as defined in Health-General Article, §10-101, Annotated Code of Maryland.

(b) "Health care provider" includes an agent, officer, director, or employee of any entity listed in §B(2)(a) of this regulation.

(3) Medical Record.

(a) "Medical record" means any oral, written, or other transmission in any form or medium of information that:

(i) Is entered in the record of a patient;

(ii) Identifies or can readily be associated with the identity of a patient; and

(iii) Relates to the health care of the patient.

(b) "Medical record" includes any:

(i) Documentation of disclosures of the medical record to any person who is not an employee, agent, or consultant of the health care provider;

(ii) File or record maintained under Health Occupations Article, § 12-403(b)(13), Annotated Code of Maryland, by a pharmacy of a prescription order for drugs, medicines, or devices that identifies or may be readily associated with the identity of a patient;

(iii) Documentation of an examination of a patient regardless of who requested the examination or is making payment for the examination;

(iv) File or record received from another health care provider that relates to the health care of a patient received from that health care provider, and identifies or can readily be associated with the identity of the patient; and

(v) To the extent not narrowed by §B(3)(a) and (b)(i)-(iv) of this regulation, "protected health information" as defined by 45 CFR § 160.103, as amended.

(4) "Medical records series" means a set of medical records, as defined in §B(3) of this regulation, that is maintained on paper, microform, magnetic disk, magnetic tape, or other medium.

(5) "Patient" has the meaning stated in Health-General Article, §4-301(j), Annotated Code of Maryland.

(6) "Person in interest" has the meaning stated in Health-General Article, §4-301(k), Annotated Code of Maryland.

(7) "Records management service" means any agent that has been procured by a health care provider to transport, handle, manage, maintain, store, or destroy medical records.

(8) "Records retention schedule" means a records management plan that includes:

(a) A list and description of the medical records series of an office or unit;

(b) The minimum retention period required to keep each medical record series;

(c) The eventual disposition instructions;

(d) If desired:

(i) Maintenance procedures, such as access or copy control, for each medical records series both in office and in storage;

(ii) Scanning or microfilming instructions; or

(iii) Disposal methods such as shredding or incineration; and

(e) A signature of approval by an individual with authority over all the medical records series listed.

(9) "Sanitizing" means overwriting, degaussing, shredding, or burning electronic or other media.

Notes

Md. Code Regs. 10.01.16.02