Medical Records and HIPPA

Legal Ethics

Accurate documentation

protects all parties by recording details of encounter and treatment

CCR

continuity of care record

T or F: medical records are not legal record, who cares if its signed

FALSE; medical records are legal records that must be signed/initialed and dated

Reasons for documentation

legal

fraud

continuity of care

malpractice

Elements of medical records

demographics

insurance information

consent forms

medical history

medications

examination and notes

lab and testing results

communication

EMR vs. EHR

EMR - electronic medical record; digital version of a paper chart and is limited to one network

EHR - electronic health record; more detailed than an EMR, is designed to be shared across multiple networks if needed

SOAP

subjective - patient’s chief complaint, history, review of symptoms

objective - result of the physician’s exam of patient

assessment - diagnosis or impression

plan - treatment

CHEDDAR

chief complain

history

examination

details

drugs and doses

assessment

return to office

How to correct a mistake in a medical record

draw a single line through the error → correct the mistake above the writing → sign and date the correction → add an addendum for additional information

Who owns a medical record?

NOT THE PATIENT; patient can only have access to their medical records

original records belong to the provider or facility

What scenarios is there no requirement for release or authorization from the patient?

criminal acts

legally ordered

communicable diseases

mandated (workman’s comp)

Minimum amount of time for retention of records in Pennsylvania

adults - 7 years after their last exam, after 3 the record is considered inactive

children - 7 years or 1 year after they turn 21

HIPPA

health insurance portability and accountability act of 1996

What is HIPPA designed for?

protect privacy of sensitive patient information

combat fraud in the healthcare industry

simplify administration of health insurance

promotes the use of medical savings plans for employees

Which HIPPA title is most related to healthcare?

Title 2 (there are 5)

Privacy rule

establishes the first national standards to protect patients’ protected health information (PHI)

limits the use and disclosure of PHI

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

requires that electronic transmissions be sent in a universal format under a secure code

Security rule

requires covered entities to take reasonable and suitable steps to protect PHI by:

ensuring confidentiality, integrity, and availability

identifying and shielding against realistic anticipated threats

protecting against unallowable uses

guaranteeing compliance

Administrative safeguards

prevents people from accessing medical records they should not be