Example of Medical Record Elements Demographics Patient Identification

Example of Medical Record Elements Demographics Patient Identification Numbers or Cards (SS#, Medical Record Number, Drivers License) Full Name Street Address City, State, Zip Code Phone Number Fax Number E-mail address URLs and IP Addresses Gender Race Religion Date of Birth Photographs Spouse Information Beneficiary Information Parent/Guardian Information Emergency Contact Information Vehicle Identification Number Biometric Identifiers (including finger and voice prints) Insurance Information Financial Information Insurance Carrier Insurance Group Numbers Copy of Insurance Card Guarantor (Responsible Party) Billing Address Employer Primary Care Provider Total Charges Claim Forms Payment History Pre-certifications or Prior Authorizations Medical Information Patient Complaints Dates of Service Admission and Discharge Dates Treating or Referring Physician, Clinic, Hospital Diagnosis Treatment Plan Immunization Record Psychotherapy Note Information Lab Tests Blood Type Medical Information (continued) Procedures Orders or Requests Patient History Personal Habits Weight Height Age Temperature Pulse History of Present Illness Dictation Symptoms Physical Findings Family Medical History Discharge Status Medications Barriers to Communication Mode of Arrival Allergies/Untoward Reactions to Drugs Reason for Encounter Request for Consultation CPT Codes ICD-9 Codes Date of Death

Limited Data Set Demographics Patient Identification Numbers or Cards (SS#, Medical Record Number, Drivers License) Full Name Street Address City, State, Zip Code Phone Number Fax Number E-mail address URLs and IP Addresses Gender Race Religion Date of Birth Photographs Spouse Information Beneficiary Information Parent/Guardian Information Emergency Contact Information Vehicle Identification Number Biometric Identifiers (including finger and voice prints) Insurance Information Financial Information Insurance Carrier Insurance Group Numbers Copy of Insurance Card Guarantor (Responsible Party) Billing Address Employer Primary Care Provider Total Charges Claim Forms Payment History Pre-certifications or Prior Authorizations Medical Information Patient Complaints Dates of Service Admission and Discharge Dates Treating or Referring Physician, Clinic, Hospital Diagnosis Treatment Plan Immunization Record Psychotherapy Note Information Lab Tests Blood Type Medical Information (continued) Procedures Orders or Requests Patient History Personal Habits Weight Height Age Temperature Pulse History of Present Illness Dictation Symptoms Physical Findings Family Medical History Discharge Status Medications Barriers to Communication Mode of Arrival Allergies/Untoward Reactions to Drugs Reason for Encounter Request for Consultation CPT Codes ICD-9 Codes Date of Death *Provided no name, patient identifier numbers, group numbers or other specific identifiers are included (i. e. , "facial identifiers").

DE-IDENTIFIED DATA Demographics Patient Identification Numbers or Cards (SS#, Medical Record Number, Drivers License) Full Name Street Address City, State, Zip Code Phone Number Fax Number E-mail address URLs and IP Addresses Gender Race Religion Date of Birth Photographs Spouse Information Beneficiary Information Parent/Guardian Information Emergency Contact Information Vehicle Identification Number Biometric Identifiers (including finger and voice prints) *No individually identifiable health information included. Insurance Information Financial Information Insurance Carrier Insurance Group Numbers Copy of Insurance Card Guarantor (Responsible Party) Billing Address Employer Primary Care Provider Total Charges Claim Forms Payment History Pre-certifications or Prior Authorizations *Medical Information Patient Complaints Dates of Service Admission and Discharge Dates Treating or Referring Physician, Clinic, Hospital Diagnosis Treatment Plan Immunization Record Psychotherapy Note Information Lab Tests Blood Type Medical Information (continued) Procedures Orders or Requests Patient History Personal Habits Weight Height Age Temperature Pulse History of Present Illness Dictation Symptoms Physical Findings Family Medical History Discharge Status Medications Barriers to Communication Mode of Arrival Allergies/Untoward Reactions to Drugs Reason for Encounter Request for Consultation CPT Codes ICD-9 Codes Date of Death