Chapter 25

Health Records

- must be maintained by hospitals, ambulatory care facilities, physician practices, emergency and trauma centers, rehabilitation centers, long-term care facilities, home care programs, and all other health care settings

Patient Care Information

- must be consolidated into one single record, which promotes effective communication among all healthcare providers involved in the patient’s care.

- Also provides for continuum of patient care

health information management department

Every health care institution needs a ___________

What a health information management department does

- Facilitates collection of health information​

- Ensures complete documentation​

- Maintains health data​

- Protects contents of the record against unauthorized disclosure (provides security of data)

What a health information management department supports

- Current and continuing care of patients​

- Institution's administrative processes​

- Patient billing and accounting processes​

- Medical education programs​

- Health services research​

- Utilization management​

- Risk management​

-Quality management (performance improvement)​

- Privacy and security issues (HIPAA compliance)​

- Legal requirements​

- Extraneous patient services

Electronic Health Records, or EHR

Health records are more commonly electronic now, and are referred to as ​​

Health Information Management

Coding Inpatient and outpatient diagnoses and procedures is managed in this department and is instrumental in insurance reimbursement

- involves converting diagnoses and procedures into a numeric classification system and are reported to Medicare and third-party payers, such as insurance companies

right to access it

The patient’s health record must be complete and readily accessible to anyone who has a _______

length of time

The _____________ a patient's record must be maintained is controlled by the Code of Federal Regulations, state law, and accreditation requirements

Length of time for retention of mammography records

- is addressed separately;

- mammograms must be retained for no less than 5 years and no less than 10 years if a patient has had no other mammogram at that facility.

- Mammograms must be transferred to other facilities upon request, and with patient’s permission

Patient Records through the Joint Commission (TJC) and Healthcare Facilities Accreditation Program (HFAP)

- Standards for the maintenance and documentation within health records have been established by these organizations​

- These organizations are authorized by the Centers for Medicare and Medicaid Services (CMS) to survey health care facilities to ensure compliance

Patient Health Records Must Include

- Patient identification data​

- Medical history, provided by patient​

- Chief complaint​

- History of present illness or injury​

- Relevant family and social history​

- Inventory of body systems

- Report of relevant physical examination findings​

- Diagnostic and therapeutic orders​

- Clinical observation and results of therapy​

- Reports of diagnostic and therapeutic procedures and tests, and their results​

- Evidence of informed consent, when applicable​

- Conclusions at termination of hospitalization or evaluation of treatment, and instructions for follow-up care

"need to know"

- Technologists often have a need to review certain aspects of the patient's chart to gather information in the performance of their duties​

- Electronic access is recorded to ensure that only those with a ___________ access the records

Radiologic Procedures

must be ordered by a qualified healthcare practitioner and must include patient information, specific procedure ordered, and diagnosis or signs/symptoms

Radiologist

interprets the radiographic study and verifies the report with signature

Written Documentation

should be made in ink and be legible

Electronic Documentation

is verified by user's computer sign in

Regulations Against Documentation Issues

such as abbreviations, a list of do-not-use abbreviations, legibility, and corrections of errors or omissions

termed quality assurance, quality assessment, and performance improvement

Quality of the care and services provided to patients within a health care facility is monitored and evaluated constantly

Performance Improvement

includes activities related to:​

- Risk management​

- Infection control​

- Surgical case review​

- Medication usage evaluation​

- Health record review​

- Blood usage review​

- Pharmacy review​

- Case management

TJC Standards

require that hospitals have a planned, systematic and hospital-wide approach to monitoring, evaluating, and improving the quality of care

Performance Improvement in Radiology

might include:​

- Adverse events​

- Medication errors​

- Adverse drug reactions​

- Patient feedback surveys​

Example of a hospital Performance Improvement Activity

- After reviewing surgical cases, it appears one surgeon has a higher post-surgical infection rate than the average.

- An investigation would be conducted to identify the source of the problem and corrective measures are planned, implemented and monitored

Patient's Health Record or Chart

- is a legal document​

- may be submitted as evidence in court cases​

Federal Regulations

affect an institution's participation in Medicare and Medicaid programs

Radiographers or other healthcare providers

may be required to give testimony or depositions regarding information in the patient's health record

If documentation in the health record is written, errors are corrected by:​

- Drawing a single line through the error and writing "Error" above it​

- Documenting the correct information, including date and signature of the person correcting the error

Patients

- have a right to review their health record and request (in writing) an amendment or correction to the record;

- must provide a reason for the request

The Physician of Record or the Institution

will review the request and respond (in writing) to the patient's request

If documentation in the health record is in an electronic format

- the procedure for correcting an error may be more complex, and is dependent on the capabilities of the EHR system.

-The procedure will be dictated by the policies at the institution ​​

safeguard

All healthcare providers have a responsibility to _________ the confidentiality of health record information

"need to know"

Most institutions track access to medical records electronically, to assess who is accessing the record and if the individual has a legitimate reason to access the record, or a ________

HIPPA (Health Insurance Portability and Accountability Act)

- regulations are designed to protect health information from inappropriate access or use

- Provides regulations for security of the electronic health records and protection of the patient's privacy

statutes

- States can enact ________ recognizing physician-patient privilege ​

- If this legislation exists, the physician could not testify in a legal proceeding without the patient's consent

Consent to Release Information

- A patient can give authorization for release of health information to the patient, a family member, another healthcare entity, or a legal representative

- Patient must sign this

- may specify to whom the information is released, and may place restrictions on which portions of the medical records may be released, or designate a treatment time frame on the release

robust plan

Healthcare entities must have a _______ in place to provide security for the electronic health record

Electronic Health Record (EHR

a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory dat,a and radiology reports

Health Information Management (HIM)

the allied health profession built around the management of the healthcare record in its physical form, as well as the management of data and information within the medical record