Health Records and Professional Ethics in Radiology

Health Information Management

All health care providers are required to maintain all patient care information that applies to an individual patient.

Health Records

Concentrate, within a single record, all patient care information that applies to an individual patient.

Health Information Department Functions

Support the current and continuing care of patients, maintenance of health information, and support the institution's administrative processes.

Patient Billing and Accounting Processes

Records maintained by the health information department for patient billing and accounting processes.

Reimbursement Formulas

Many reimbursement formulas are contingent upon medical records and their accuracy.

Performance Improvement Programs

Maintain records for utilization management, risk management, and quality management or performance improvement programs.

Patient Privacy and Security

Ensure patient privacy and security issues.

Legal Compliance

Ensure compliance with legal requirements.

HIPAA

Health Insurance Portability and Accountability Act 1996, a federal law that required the creation of national standards to protect sensitive patient health information.

HIPAA Privacy Rule

Addresses the use and disclosure of individuals' health information by entities subject to the Privacy Rule.

Protected Health Information

Health information that is protected under the HIPAA Privacy Rule.

Individuals' Rights

Individuals have rights to understand and control how their health information is used.

Major Goal of the Privacy Rule

To ensure that individuals' health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care.

Balance of Privacy and Information Flow

The Privacy Rule strikes a balance that permits important uses of information while protecting the privacy of people who seek care.

Continuity of Care

Health records promote effective communication and ensure continuity of care.

Service-oriented Health Information Department

The Health Information department is service-oriented.

Documentation Errors

Discuss the procedure for correcting or amending documentation errors in a patient health record.

Coding in Radiologic Procedures

Identify coding as it relates to radiologic procedures and the reimbursement impact for health care facilities.

Confidential vs Non-Confidential Information

Differentiate between confidential and non-confidential information.

Health Services Research

Support health services research as part of health information management.

APC

Ambulatory Patient Classification

CPT

Current Procedural Terminology

ICD-10-CM

International Classification of Diseases, 10th edition, Clinical Modification

DRG

Diagnosis-Related Group

TJC

The Joint Commission

HFAP

Healthcare Facilities Accreditation Program

PPS

Prospective Payment System

CPT-4

listing of medical terms and codes for diagnostic and therapeutic procedures used for coding for physician reimbursement (used for both inpatient and outpatient)

ICD-10-CM

classification system that is used for diagnosis coding in all health care settings in the United States

DRG

categorizes into payment groups patients who are medically related with respect to diagnosis and treatment and statistically similar with regard to length of stay

TJC

organization that accredits hospitals and other health care institutions in the United States

HFAP

performs functions similar to TJC

PPS

system for Medicare patients whereby payment groups are established in advance; hospitals get paid up front

EMR/EHR

electronic health record system generally considered as the portal through which clinicians access a patient's health record, order treatments or therapy, and document care delivered to patients; allows providers to gather multiple types of data about a patient

PA chest (single view)

71010

MR cervical spine/contrast

72142

Health Records Coding

Converts diagnoses and procedures into a numerical system

Accurate coding

greatly impacts reimbursements from Medicare and third-party payers.

Health Record Content

All departments that take part in the care of a patient must document that care in the health record.

Charting

Documenting in the patient's record, or charting, should be done by radiologists and radiographers when a patient receives either diagnostic or therapeutic radiologic services.

Medical necessity

a diagnosis or sign or symptom for which the test is being performed must accompany each request for all procedures ordered.

Patient ID and demographics

Information identifying the patient and their demographic details.

Medical history

A record of the patient's past health issues and treatments.

Conclusion and impression on admission

The assessment made by the healthcare provider upon the patient's admission.

Diagnostic and therapeutic orders

Instructions for tests and treatments to be performed.

Clinical observations

Notes made by healthcare providers regarding the patient's condition.

Report of relevant physical examination

Documentation of the findings from the physical examination of the patient.

Consultation reports

Reports from specialists who have evaluated the patient.

Diagnostic and therapeutic reports

Documents detailing the results of diagnostic tests and therapeutic interventions.

Final diagnosis and prognosis

The conclusive diagnosis made and the expected outcome for the patient.

Discharge summary

A summary of the patient's hospital stay and instructions for follow-up care.

Postmortem results

Findings from examinations conducted after a patient's death.

Psychologic needs summary

An overview of the psychological support required by the patient.

Physical examination report

A detailed account of the physical examination findings.

Treatment plan

A documented strategy for managing the patient's condition.

Evidence of informed consents

Documentation showing that the patient has agreed to treatment after being informed of the risks.

Progress notes

Ongoing documentation of the patient's condition and treatment progress.

Reports of surgical and invasive procedures

Documentation of surgeries and other invasive treatments performed on the patient.

Records of donations and implants

Documentation of any organ donations or implants related to the patient.

Conclusions at termination of stay

Final assessments made at the end of the patient's hospital stay.

Discharge info given to patient and family

Information provided to the patient and their family upon discharge.

Follow-up care instructions

Guidelines provided for the patient's care after discharge.

Patient demographic information

Details about the patient's identity and background.

Specific procedure requested

The particular medical procedure that has been ordered.

Ordering physician

The doctor who has requested a specific procedure or treatment.

Documentation of medical necessity

Records that justify the need for a specific medical service or procedure.

Requires a diagnosis or symptoms

Indicates that a medical procedure must be supported by a diagnosis or presenting symptoms.

Procedure results

Outcomes or findings from a medical procedure performed.

Dosage required for therapeutic and radionuclide procedures

The specific amount of medication or radioactive material needed for treatment.

Special reports documenting evaluation or treatment of a patient

Detailed reports that provide insights into the patient's evaluation or treatment.

Provided by radiologist

Indicates that the report or findings were generated by a radiologist.

Patient images kept in department PACS system

Medical images of the patient stored in the Picture Archiving and Communication System.

Report also maintained in radiology EHR

The report is also stored in the electronic health record of the radiology department.

Reports must be signed by interpreting radiologist. Electronic signature

All reports need to be signed by the radiologist who interpreted them, using an electronic signature.

Reports are transcribed. Voice-activated transcription

Reports are converted into written form using voice-activated transcription technology.

Do's

Guidelines for proper documentation practices in medical records.

Don'ts

Prohibited actions when recording information in medical records.

Patient identification data

Information used to identify the patient within the medical records.

Medical history of the patient

A comprehensive record of the patient's past medical conditions and treatments.

Clinical observations, including results of therapy

Notes on the patient's clinical status and the outcomes of any therapies administered.

Informed Consent

A process ensuring the patient is aware of and agrees to the treatment or procedure.

Incident Report

A document detailing incidents or occurrences that deviate from standard patient care.

Quality assurance

A process that monitors and evaluates the quality of the care and services provided to patients within a health care facility.

CQI measures

Continuous Quality Improvement measures used to enhance the quality of services.

Radiology order

A request for service that must accompany a diagnosis or sign or symptom for which the test is being performed.

EMR

Electronic Medical Record, where results of the procedure should be documented as soon as possible after completion.

Health Insurance Companies

Entities that require medical records to support the diagnosis for reimbursement under the diagnosis-related group (DRG) and the prospective payment system (PPS).

DRG

Diagnosis-Related Group, a system implemented by the government in 1983 for reimbursement purposes.

PPS

Prospective Payment System, a method for reimbursing healthcare providers.

Failure to Record Data

The requirement that records must be in ink or verifiable if using an Electronic Health Record system.

Performance Improvement

A process that includes monitoring and evaluating the quality of care and services provided to patients.

Utilization

The measurement of how services are used within a healthcare facility.

Risk management

The identification and mitigation of risks within a healthcare setting.

Infection control

Measures taken to prevent the spread of infections in healthcare facilities.

Surgical case review

An evaluation of surgical cases to ensure quality and safety.

Medication usage

The assessment of how medications are prescribed and administered.

Health record review

The process of evaluating patient records for accuracy and completeness.

Blood usage review

An analysis of how blood products are utilized in patient care.

Pharmacy and therapeutic review

An evaluation of pharmacy practices and therapeutic outcomes.

Case management

The coordination of patient care to ensure effective treatment.