Week 6 - Confidentiality and Documentation

Verbal Communication

Good in emergencies, quick responses, sensitive topics

Written Communications

EMR notes, detailed info to remember, legal documentation, insurance documentation

Virtual Communications

Wide scale communication across departments, more accessible patient care, quick check ins

EMR Uses

Clinical, legal, reimbursement, operations, education, research

EMR Addendums

All access recorded, nothing can be deleted when saving, edits notated with a slash through for documentation purposes

SOAP Notes - Subjective

What patient tells you how they feel, past med/social history, chief complaint

SOAP Notes - Objective

Everything you see, hear, smell, feel, and learn from tests and procedures

SOAP Notes - Assessment

Using data collected to form a list of patient’s problems

SOAP Notes - Plan

Implementation and evaluation of results

HIPAA

Health insurance portability and accountability act of 1996

“P” in HIPAA - Privacy

Gives certain protection when individuals health care coverage changes

“A” in HIPAA - Accountability

Privacy of patient’s information

Requirements for HIPAA

Under HIPAA, those that use or disclose individually identifiable health information, known as protected health information, are subject to the HIPAA privacy rules

Accessing Information

Never access PHI unless you need to know that information to provide care or complete a work related task

The Joint Commission

Provides standards for documentation/accreditation for content charted, level of detail, and frequency

Negligence

A failure to behave with the level of care that someone of ordinary prudence would have exercised under the same circumstances (can also include omissions when there’s duty to act)

Requirements for Negligence

1. Defendant owed a duty of care to the plaintiff

2. Defendant breached that duty

3. Plaintiff suffered a legally recognizable injury

4. Defendant’s breach of duty of care caused the plaintiff’s injury