week 8 presentation medical law
TRANSCRIPT
Patient Record Requirements
By: Kenda ColemanWeek 8 Medical Law PresentationTime Spent: 3 hours
Health information professionals have traditionally influenced the risk management process by implementing, enforcing, and educating health care providers about patient records requirements.
Purposes medical records are used
HIPAA Risk Compliance Categories
Proper documentation
Security Issues
Retaining Records
Confidentiality
Privacy Rule
Benefits and Drawbacks of going paperless
This is an outline of today's presentation.
Purposes of a Medical Record
Providing a basis for evaluating the adequacy and appropriateness of care
Providing a means of communication between the physician and the other member of the health care team caring for the patient
Providing data to insurance claims
Protecting the legal interests of the patient, facility, and the physician
Providing clinical data for research and education
HIPAA Risk Compliance Categories
Risk Assessment
Currency of Policies and Procedures
Security Awareness and Training
Workforce Clearance
Workstation Security
Encryption
Proper Documentation
Proper documentation is timely and complete. This means that all entries in the record are authored and authenticated and reflect the total care actually rendered to the patient
A properly documented health record benefits a health care provider's defense in a law suit. It is both timely and complete, and it meets the appropriate requirements for record content.
A complete timely and accurate record reduces risk at trial because the health care providers defense ability is enhanced.
Security Issues
Security issues regarding a risk management program centers on the availability of health records for purposes of patient care, access to patient specific information, retention of records and database management.
Falure to make health records availaible during a current or subsequent episode of patient care may result in harm to the patient and exposure of the health care provider to liability.
Security Issues
Requests for access to patient-specific health information should be handled only by those with proper training and supervision
Health Care facilities reduce the risk of a lawsuit for negligent loss of record by retaining records for the minimum period
Retaining Records
The medicare Conditions requirements apply to hospitals or similar facilities. The Medicare Conditions of Participation require hospitals to retain records 5 or 6 years (depending on critical access hospitals).
Adult patients 10 years from the date the patient was last seen
Minor patients 28 years from the date of birth
Decesed patients 5 years from date of death
OSHA requires 30 years to be retained for employees that have been exposed to toxic or harmful substances.
Confidentiality
Confidentiality is the obligation of the health care provider to maintain patient information in a manner that will not permit dissemination beyond the health care provider
The failure of health care providers to respect confidentiality will have an in pack on risk management programs through an increased number of lawsuits.
Privacy Rule gives you the right to inspect, review, and receive a copy of your medical record and billing record that are held by health plans and health care providers covered by the privacy rule. One exception is that a patient access to the providers psychotherapyherapy notes.
Pros of going paperless
Save time with billing and scheduling tasks
Easily attach media files to patient records
Export documents quickly
Reduce overall transcription costs by eliminating many tasks
Streamline office workflow
Assign staff members documents electronically for review
Free up storage space in filing cabinets and the office
Eliminate paper and lessen other supplies costs
Drawbacks of going paperless
You will need to make sure all computer hardware and software programs are up-to-date and perform system-wide upgrades regularly to prevent any gaps in data transfers and losses. You will also need to make sure all computer systems are password-protected and connected to a secure server. You will need to back up data regularly and implement a system for restoring data in the event of an emergency. Another thing to consider is that it may take time to train staff members how to scan and save documents for easy retrieval.
References
Legal and Ethical Aspects of Health Information Management (Fourth Edition class textbook pages 270-275)
The Doctors Company (2016) www.thedoctors.com/KnowledgeCenter/PatientSafety/articles/MedicalRecord-Rention
U.S. Department of Health and Human Services (HHS.gov) www.hhs.gov/hipaa/for-individuals/medical-records/index.htm.
AHIMA Practice Brief http://www.patientnow.com/pros-cons-going-paperless-emr/