Medico-Legal Guidelines Appendix A-2

Appendix A-2

Pertinent North Carolina Statutes And Regulations Regarding Medical Records

"Medical records" are defined by the following North Carolina statutory or regulatory provisions:

• N.C. Gen. Stat. § 8-44.1 (2005) ¹
  
• N.C. Gen. Stat. § 90-410(2) (2005)²
  
• N.C. Gen. Stat. § 58-39-15(18) (2005)³
  
• N.C. Gen. Stat. § 130A-372 (2005)⁴
  
• 10A N.C. Admin. Code § 14J.0101 (2005)⁵
  
• 10A N.C. Admin. Code § 14J.1701 (2005)⁶

• Individuals receiving services for mental health, substance abuse, or mental retardation are referred to as "clients," and information about their treatment is called "confidential information," defined in N.C. Gen. Stat. § 122C-3(9) (2005).⁷ Compilations of such information are sometimes called the "client record." ⁸ Note that substance abuse information also is likely to be subject to the strict provisions of the federal drug and alcohol abuse facility law.
  
  
• Both §130A-45.8 (2005),⁹ concerning patient information held by public health authorities, and § 131E-97 (2005)¹⁰, addressing patient information held by "health care facilities," draw a distinction between the patient's medical records and financial records.
  
  
• N.C. Gen. Stat. § 131E-214.1 (2005) defines both "patient data" and "patient identifying information."¹¹
  
  
• Medical information governed by the Division of Aging and the Division of Social Services is considered "client information."¹²
  
  
• 10A N.C. Admin. Code 47B.0102(6) (2005) defines "identifying information" with respect to cancer patients.¹³
  
      1. "Hospital medical records" are defined as "records made in connection with the diagnosis, care and treatment of any patient or the charges for such services except that records covered by N. C. Gen. Stat. § 122-8.1, N. C. Gen. Stat. § 90-109.1 and federal statutory or regulatory provisions regarding alcohol and drug abuse, are subject to the requirements of said statutes." (Please note that N.C. Gen. Stat. § 122-8.1 and N.C. Gen. Stat. § 90-109.1 have been repealed).
  
      2. Medical records are defined as "personal information that relates to an individual?s physical or mental condition, medical history, or medical treatment, excluding X-rays and fetal monitor records."
  
      3. Information about patients is subject to three definitions under N.C. Gen. Stat. § 58-39-15 of the North Carolina insurance statutes:
  
  1. "Medical-record information" means personal information that:
     
     1. Relates to an individual's physical or mental condition, medical history, or medical treatment; and
     
     
     2. Is obtained from a medical professional or medical-care institution, from the individual, or from the individual's spouse, parent, or legal guardian.
     
     
  2. "Personal information" means any individually identifiable information gathered in connection with an insurance transaction from which judgments can be made about an individual's character, habits, avocations, finances, occupation, general reputation, credit, health, or any other personal characteristics. "Personal information" includes an individual's name and address and medical-record information, but does not include privileged information.
  
  
  3. "Privileged information" means any individually identifiable information that (i) relates to a claim for insurance benefits or a civil or criminal proceeding involving an individual, and (ii) is collected in connection with or in reasonable anticipation of a claim for insurance benefits or civil or criminal proceeding involving an individual: Provided, however, information otherwise meeting the requirements of this subsection shall nevertheless be considered personal information under this Article if it is disclosed in violation of N.C. Gen. Stat. § 58-39-75 (2005).
  
      4. Medical records are defined as "health data relating to the diagnosis or treatment of physical or mental ailments of individuals."
  
      5. The medical record of an inmate of a local confinement facility is defined as "a record of medical problems, examinations, diagnoses and treatments."
  
      6. The definition in footnote 4 also applies to inmates in municipal lock-up facilities.
  
      7. "Confidential information" is defined in § 122C-3(9) as:
  

  ...any information, whether recorded or not, relating to an individual served by a facility that was received in connection with the performance of any function of the facility. 'Confidential information' does not include statistical information from reports and records or information regarding treatment or services which is shared for training, treatment, habilitation, or monitoring purposes that does not identify clients either directly or by reference to publicly known or available information.

  
  10A N.C. Admin. Code 26B.0103(b)(3) (2005) further provides that confidential information as defined in Section 122C-3 "includes but is not limited to photographs, videotapes, audiotapes, client records, reimbursement records, verbal information relative to clients served, client information stored in automated files, and clinical staff member client files."
  
      8. The Administrative Code has several slightly differing definitions for this information. 10A N.C. Admin. Code 26B.0103(b)(1) (2005) defines "client record" as "any documentation made of confidential information." 10A N.C. Admin. Code 26D.0103(8) (2005) defines "client record" as "a written account of all mental health and mental retardation services provided to an inmate the time of acceptance of the inmate as the client until termination of services. This information is documented on standard forms which are filed in a standard order in an identifiable folder." 10A N.C. Admin. Code 27G.0103(b)(12) (2005) defines "client record" as "a documented account of all services provided to a client." 10A N.C. Admin. Code 21A.0201(22) (2005) contains this definition: "'client information' or 'client record' means any information, including information stored in computer data banks or computer files relating to a client that was received in connection with the performance of any function of the agency." 10A N.C. Admin. Code 28A.0102(b)(6) (2005) defines "client record" as "any record made of confidential information."
  
      9. N.C.G.S. § 130A-45.8 (2004) provides:
  
  1. Medical records compiled and maintained by public health authorities in connection with the admission, treatment, and discharge of individual patients are not public records as defined by Chapter 132 of the General Statutes.
  
  
  2. Charges, accounts, credit histories, and other personal financial records compiled and maintained by public health authorities in connection with the admission, treatment and discharge of individual patients are not public records as defined by Chapter 132 of the General Statutes.
  
      10. Section 131E-97 (2005) provides:
  
  1. Medical records compiled and maintained by health care facilities in connection with the admission, treatment, and discharge of individual patients are not public records as defined by Chapter 132 of the General Statutes.
  
  
  2. Charges, accounts, credit histories, and other personal financial records compiled and maintained by health care facilities in connection with the admission, treatment, and discharge of individual patients are not public records as defined by Chapter 132 of the General Statutes.
  
      11. Section 131E-214.1, concerning statewide data processing of certain information about patients, includes the following definitions:
  
  1. "Patient data" means data that includes a patient's age, sex, zip code, third-party coverage, principal and other diagnosis, date of admission, procedure and discharge date, principal and other procedures, total charges and components of the total charges, attending physician identification number, and hospital or freestanding ambulatory surgical facility identification number.
     
  2. "Patient identifying information" means the name, address, social security umber, or similar information by which the identity of a patient can be determined with reasonable accuracy and speed either directly or by reference to other publicly available information. The term does not include a number assigned to a patient by a health care provider if that number does not consist of or contain numbers, including social security or drivers license numbers, that could be used to identify a patient with reasonable accuracy and speed from sources external to the health care provider.
  
      12. Both 10A N.C. Admin. Code 5J.0101(3) (2005) and 10A N.C. Admin. Code 69.0101(3) (2005) provide that "'client information' or 'client record' means any information, whether recorded or not, including information stored in computer data banks or files, relating to a client which was received in connection with the performance of any function of the agency."
  
      13. The pertinent regulation defines "identifying information" as "any portion of any abstract or incidence report that might reveal the personal identity of a cancer patient." All health care facilities and providers that detect, diagnose, or treat cancer shall report to the central cancer registry each diagnosis of cancer in any person who is screened, diagnosed or treated.
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