chap 23: the med record documentation & filing

What types of information do medical facilities generate?

Business, personal, and financial information, such as licenses, certifications, and insurances, with most relating to medical care.

Why must malpractice policies and medical records be kept long-term?

Because of the discovery rule—claims can be filed years later after harm is discovered.

How has technology impacted medical record retention?

It has simplified and made long-term storage easier.

Chart/Progress/Clinical Notes/CHARTING

What happened during the visit. Recited the patient’s encounter with the medical facility. It is also relevant to legal issues such as documenting an injury for litigation.

How can charting serve as defense?

Shows what was done, when, and why. In an abandonment action — when a pt is left without care — good charting shows that the provider met their obligations and followed proper procedures.

What rights does HIPAA give patients regarding their medical charts?

HIPAA allows patients the right to access their medical chart. It also provides guidelines on how long a facility has to supply those requested records.

What is included in a patient’s medical record?

Personal, personal medical history, family history, social habits, medications, occupational exposures, and tests. This is known as PHI (protected health information) under HIPAA.

Stakeholders

Who is affected/interested by the record = hospital, insurance act company, patient, maybe employer

Malpractice

MD failed to follow the accepted standard of care; did something no other MD would do

Demographic information

Sex, age, ethnicity, occupation, and religion

Abandonment

MD failed to treat pt when shoukd’ve

Subpoena role in medical information

An exception to getting pt to sign off—so even without patient permission, a court can demand the records. Once someone is served a subpoena, they typically have about 10 days to ask a judge to block it if they think it’s not right.

And even with these exceptions, the info released still has to be the minimum necessary—that means only the smallest amount of information needed for the case.

_______ records and _______ records require additional authorization, such as a court order.

Mental health records and substance abuse records

Is a provider ethically obligated to share the chart with another doctor taking over care?

Yes, they are. However, a chart cannot be withheld for unpaid fees, and if fees aren’t paid by the pt, a lawsuit is the proper way to collect them (civilly)

Audit

A review of the charts by the insurance company to verify that the proper payment has been made

Interoperability

The various EHR systems to communicate with each other.

Difference between primary and specialist

Primary treats multiple conditions and specialist treats 1 or 2

HCPS “Hickpicks”

Allows MD to bill out non medical services. Can bill out a hospital bed, cane, walker, vaccine.

CPT

Current procedural terminology. What did I do to you? (Examined/consult?). Code that is used to describe a medical service so it can be billed and tracked correctly.

ICD

International classification of diseases is the diagnosis code. What do I think is wrong with you? The reason for care.

• ICD and CPT code must agree.

  • You get a flu shot → CPT code = the injection

  • You have the flu or need prevention → ICD code = the reason/condition

What is the importance in keeping good medical records?

Patient care, licensing issues, defense in a malpractice or fee dispute

HIPAA privacy rule

Keep patients medical information secure.

HIPAA privacy officer

Monitor the facilities’ compliance with HIPAA regulations.

HIPAA security rule

Medical records need to be kept safe and secure from hackers or other threats.

Risk analysis

Regularly checking system to find weak spots. Look at the system, when you could be hacked or vulnerable needs to be fixed.

If a breach affects more then ____ people in a _____ state, then you have to _______ it to the authorities.

500, single, self report

Mandatory reporting

Certain events have to be reported by law. It includes things like birth deaths, injuries from violence, measles, child abuse.

How are medical records used in court cases?

Medical records can be used in malpractice and personal injury cases. Both the plaintiff and defendant use them, and they can also show pre-existing conditions.

SLIDE 6