What’s in a health record?
Every time a University Health Services (UHS) provider or medical or mental health care staff member interacts with a patient—in an appointment, on the phone, or through Secure Messaging—information is documented in the patient’s confidential health record (also called ‘medical record’). The UHS Health Information Management (HIM) Department manages medical records within the patient’s electronic health record (EHR) and paper healthcare records. A patient’s medical record is a collection of these documented interactions.
This is an accordion element with a series of buttons that open and close related content panels.
Common documentation found in UHS health records (includes but not limited to):
- Advance directives
- Copies of referrals received/placed
- Consent for treatment forms
- Consultation and referral records
- Documents received from other clinics (i.e., previous medical records)
- Encounter/visit notes
- Financial and billing records
- Health history forms
- Immunizations
- Lab reports
- Medications and medication orders
- Patient submitted documentation
- Photographs
- Problem lists
- Questionnaires
- Radiology films (i.e., X-rays) and associated reports
- Secure messages between student and UHS clinician
- Surveys
Contact Us
Phone: 608-262-1676
Fax: 608-262-9160
Email: him@uhs.wisc.edu
333 East Campus Mall, 8th floor
Protecting your privacy
Whether you’re a student or a non-student, the confidentiality, privacy, and security of your medical records are the responsibility of the health care facility that owns them, but you can help maintain confidentiality:
- Be aware of what personally identifiable information and protected health information is collected.
- Be aware of who collects personally identifiable information and protected health information.
- Understand who manages UHS medical records.
- Ask about UHS’s confidentiality practices.
- Read the fine print before you authorize the release of your confidential health information or consent for treatment at UHS.
- Confirm the authorization specifies the recipient and the purpose of release accurately.
To learn more about how UHS protects your privacy and patient rights, visit our Privacy and Patient Rights page.
Federal and state health privacy laws
The privacy of your medical records maintained by UHS are protected by federal and state laws. The primary laws governing patient privacy and confidentiality are listed below (this is not an exhaustive list).
To ensure compliance with these laws, UHS does not disclose information to family members, or others, without your consent or authorization. However, in an emergency, our professional staff will exercise professional judgment to determine if family members, usually parents, should be informed of the situation even if the student withholds consent.
This is an accordion element with a series of buttons that open and close related content panels.
Federal Laws
Wisconsin Laws
146.81-.84 – Miscellaneous Health Provisions: Health Care Records
146.816 – HIPAA Harmonization – Mental Health Care Coordination
153.5 – Protection of Patient Confidentiality
51.30 – Mental Health Act: Records
943.201 – Unauthorized Use of an Individual’s Personal Identifying Information or Documents
Release of Information
This is an accordion element with a series of buttons that open and close related content panels.
Patients
UHS requires that all requests for confidential health information are submitted in writing. Most of your medical records are available to you in MyUHS.
To request a copy of your medical records you can:
- Submit a request to him@uhs.wisc.edu or
- Send a Secure Message to the Health Information Management Department in MyUHS.
To send or share a copy of your medical records with someone, you must complete an Authorization for Release of Health Records. To ensure the highest level of privacy and confidentiality, submit your authorization through Downloadable Forms in MyUHS.
You will be required to show proper identification (e.g., valid UW student ID or driver’s license) to pick up your records in person. You may also request that your records be mailed or sent electronically.
Special permission is required to release healthcare records regarding alcohol or other drug assessments/treatments, HIV/AIDS testing/treatment, or mental health services.
Requests to release healthcare records for continuity of care purposes will be fulfilled within five business days after the request was received. If reasonable, same day or urgent requests may be honored. All other requests will be completed within 30 calendar days after the request was received. If we’re unable to complete the request within 30 calendar days, we may extend the time by no more than an additional 30 days. In these circumstances, we will inform you, in writing, of the reasons for the delay and the date by which we will provide access.
Parents/Guardians/Family Members of Students
Parents or loved ones who are concerned about a student’s non-emergent health care situations should ask their student to grant UHS permission to speak with them.
UHS requires written authorization to formally release or discuss healthcare records but, in situations where obtaining written authorization may be impractical or urgent, students may grant permission over the phone for UHS clinical staff to speak with a parent or guardian.
With a student’s permission, UHS providers may speak with parents, and appreciate parental involvement in their student’s care, when it is appropriate. UHS providers work closely with students and their parents when a student experiences a significant, but not life threatening, illness or injury. Providers encourage students to allow them to contact their parents in these cases. However, if the student declines, the clinician legally must respect the student’s decision.
Blanket Authorizations
Patients cannot sign a blanket authorization for any use or disclosure of their healthcare information. We do not accept blanket authorizations. We require patients to submit an authorization to release healthcare information unless it meets the permissible exceptions listed in the UHS Notice of Privacy Practices.
Advance Directives
You have the right to receive information about and assistance with advance directives and designating someone (known as a designated agent or power of attorney for health care power of attorney) to make health care decisions for you in the event you are unable to. Being a designated agent for advance directives or a power of attorney for health care does not automatically allow access to confidential health care information.
Maintain Personal Health Records
We strongly encourage you to maintain personal health records to quickly access health information when necessary. However, most of your healthcare information will be available to you on the MyUHS patient portal.
This is an accordion element with a series of buttons that open and close related content panels.
Documents to consider maintaining in your personal health record include, but are not limited to:
- Advance directives
- Allergies (to medications or others)
- Contact information for your primary care clinician, dentist, optometrist, and pharmacist
- Current medications
- Dental information
- Emergency contacts(s)
- Eye prescription
- Health insurance information
- Immunization dates
- Important test results (e.g., X-rays, MRI, CT)
- Organ donor authorization
- Personal identification
Contact
Health Information Management
333 East Campus Mall, 8th floor
Phone: 608-262-1676
Fax: 608-262-9160
Email: him@uhs.wisc.edu