Health Information Technologies and Processes

What is considered "Entire Record" for Counseling Record ROI?

  • 1.  What is considered "Entire Record" for Counseling Record ROI?

    Posted 11-05-2019 18:57
    Hello All,

    In the AHIMA ROI Toolkit, it lists the "Standard Abstract" for items to be disclosed from a medical record when a Patient or Physician requests copies of "Entire Record".  The "Standard Abstract" includes: history and physical, progress notes, procedure notes, consultation reports, medication list, immunization record, and test reports (ECG's, lab, pathology, etc.). Special situations may include copies of photographs or films.

    What is considered the "Standard Abstract" when the "Entire Record" for counseling/mental health records are requested?  Where is the best resource for guidelines concerning counseling/mental health records?

    Thanks so much for all input!

    Carol Taber
    Health Information Coordinator Ii

  • 2.  RE: What is considered "Entire Record" for Counseling Record ROI?

    Posted 12-13-2019 10:34

    You need to be careful with MH records and remember minimal necessary is always a factor.  Your facility should have a policy that defines what they what to be an Abstract for MH records and then the process to release them.   We have a MH provider review and authorization release of the records prior to releasing them to anyone.

    Good luck,
    Tennille Schmitt, RHIT
    NYHIMA Communications Director

    Tennille Schmitt
    Medical Records Supervisor

  • 3.  RE: What is considered "Entire Record" for Counseling Record ROI?

    Posted 12-16-2019 10:01
    I would be interested in seeing someone's example of a MH or SA  abstract when the entire record is requested.   Sometimes we get a request for records dating back 10 years.  How do others handle those requests?  It could be 100s of pages long.

    Kathryn Boyes
    Director, HIM

  • 4.  RE: What is considered "Entire Record" for Counseling Record ROI?

    Posted 01-01-2020 09:10
    I work in Behavioral Health and also encounter requests for records dating back many years. Typically, I reach out to the requester to confirm their need and let them know the page count could be quite high. I often suggest disclosing assessments, medication history, treatment plans, and discharge summaries.  I let them know progress notes can really up the page count.

    Pamela [LastNam
    Medical Records Tech/Privacy Officer

  • 5.  RE: What is considered "Entire Record" for Counseling Record ROI?

    Posted 01-02-2020 09:30

    We would typically reach out to a requestor for any type of record request, not just MH/SA when asking for a large volume of records. We work with them on identifying what their record needs are and par down the page count wherever possible, and suggest a core record set as a starting point. 


    Stephanie Luthi-Terry, MA, RHIA, CHPS, FAHIMA

    Director, Enterprise HIM Integration • Health Information Management • Allina Health

    Phone (Primary): 612-262-0980  •

    Mail Route 10609 – 2925 Chicago Avenue,     Minneapolis, MN  55407


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