Transcript Examples of Limited Data Sets and De

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