Patient Care Chpt. 9 Medical Records and HIPPA

Accurate documentation

Protects all parties by recording details of encounter and treatment, “If not documented, it did not happen”

Accurate documentation

Provides patient’s past and present medical history as a continuity of care record (CCR), allows for communication between healthcare team, protection in cases of negligence and malpractice, research and quality control, documentation for billing and coding

Accurate documentation

Protects all parties by recording details of encounter and treatment, “If not documented, it did not happen”

Accurate documentation

Provides patient’s past and present medical history as a continuity of care record (CCR), allows for communication between healthcare team, protection in cases of negligence and malpractice, research and quality control, documentation for billing and coding

Medical records

Can differ in how it is organized, what it contains, and who is responsible for maintaining records.

Medical records

All documentation must be signed or initialed and dated

Medical records

Considered a legal record and may be requested or subpoenaed

Elements of medical records

Demographics, insurance info, consent forms, medical history, medications, examination and notes, labs and testing results, communication

Reasons for documentation

Legal, fraud, continuity of care, malpractice

Electronic records

Electronic medical record (EMR) and Electronic health record (EHR)

Electronic medical record

Digital version of paper chart, contains all information from one healthcare provider, not shared

Electronic health record

Electronic clinical documentation, includes multiple providers, designed to be shared and allow instant access for authorized users

SOAP and CHEDDAR

Way to organize documentation/notes

SOAP

Subjective, objective, assessment, plan

Subjective

Patients chief complaint, history of present illness, past medical history, family history, review of symptoms

Objective

Results of physicians exam of patient

Assesment

Diagnosis or impression

Plan

Treatment- includes prescribes medications, patients instructions, recommendations for procedures or tests

CHEDDAR

more detailed, chief complaint, history, details, drugs and doses, assessment, return to office

Only acceptable way to correct mistake

Draw single line through error, write corrected entry above it, may add an addendum for more info, initial and date correction

Dictated or typed notes

Every note or change dictated must be initialed and dated by transcript, initialed and dated by the provider to show approval

Correction and amendments to medical records

Changing a mistake

Correcting electronic medical records

Same basic principals as paper records, original entry should be viewable, person making change identifiable, reason for change noted, amended record should be flagged as corrected

No

Do patients own medical records

Ownership of records

Record of physicians work with the patient, physicians tool for helping to ensure continuity of care

Ownership of records

Patient does have right to access, and can authorize other to acess

Provider or facility

Original records belong to:

Privacy and release of information

Release of information only done with signed written release from the patient, no requirements for release or authorization in certain situations

No requirement for release or authorization from the patient

Criminal acts, legally ordered, communicable diseases, mandated

Retention of medical records

Regulations vary among states, statues of limitations, majority stored for approx 10 years from final entry, active vs inactive files

5

How many HIPPA titles are there

Health insurance portability and accountability act of 1996

Designed to protect privacy of sensitive pt info, combat fraud in the healthcare industry, simplify admin of health insurance, promote use of medical savings plans for employees

2

What title of HIPPA is most relevant to healthcare

Privacy rule

Establishes first national standards to protect patients protected health information (PHI), limits the use and disclosure of PHI

Privacy rule

Requires healthcare providers to account for any disclosures of PHI for billing or administrative purposes

Privacy rule

Requires that electronic transmissions be sent in a universal format under a secure code to de-identify the patients information

Security rule

Requires covered entities to take reasonable and suitable steps to protect PHI

Security rule

ensuring confidentiality, integrity, and availability of all e-PHI they create, receive, maintain, or transmit

Security rule

Identifying and shielding against realistic anticipated threats to the safety or integrity of the formation

Security rule

protecting against reasonably predictable unallowable uses or disclosures, guaranteeing compliance by their workforce

Administrative safeguards

Policies and procedures documented in writing to show how entities will comply should include methods for clearing or authorizing access to PHI, should have a plan for continuing training and education of employees, may appoint a staff member as security officer

Physical safeguards

Refers to the physical monitoring and access to PHI, requires that hardware and software used by covered entities be installed and removed properly to protect PHI, includes physical storage and access to workstations, “double lock system”

Technical safeguard

Responsibility of the healthcare provider to monitor and safeguard PHI through all technology-relayed items we use, data must be secured at the point of use in the facility and at the receiving end of any communication, methods include data encryption and anti-virus protection, firewalls

4

How many categories of HIPPA violations

Cat. 1

CE unaware of violation and could not have been avoided

Cat 2

CE should be aware of violation but could not have avoided it

Cat 3

Violation is a result of “willful neglect” but an attempt has been made to correct violation

Cat 4

Violation constituting “willful neglect” with no attempt to correct the violation

Office of inspector general and states attorney general

Who monitors HIPPA violation penalties

Cat 1

Minimum find of $100 per violation (max 50,000)

Cat 2

Minimum fine of $1,000 per violation (max 50,000)

Cat 3

Minimum fine of $10,000 per violation (max 50,000)

Cat 4

Minimum fine $50,000 per violation

HIPPA violation penalties (criminal)

Tier 1, tier 2, tier 3

Tier 1

Reasonable cause or no knowledge of violation - up to 1 year in jail

Tier 2

Obtaining PHI under false pretenses - up to 5 years in jail

Tier 3

Obtaining PHI for personal gain or with malicious intent - up to 10 years in jail