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

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

    Posted 13 days ago
    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!


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    Carol Taber
    Health Information Coordinator Ii
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