Chapter 9 & 10- The Medical Record/ Patient Confidentiality and HIPPA

2. in the eyes of the court

"if its not documented, it wasn't done"

* Storage (4)

1. Current records usually kept within physician's office 2. May rent storage space 3. May be placed on microfilm 4. Kept in fire-proof, locked area

* Electronic medical records (3)

1. Data on patient records can be created, modified, authenticated, stored, and retrieved by computer 2. Special safety measures should be taken to establish personal identification and user verification codes for access to records 3. Should be accessed on need-to-know basis

*Corrections and alterations (5)

1. Draw one line through error 2. Write correction above error 3. Date and initial change 4. Do not erase or use correction fluid 5. Falsification of medical record is grounds for criminal indictment

* Retention and storage of medical records (3)

1. Each state varies on length of time records must be kept 2. Legally, records must be stored for a minimum of ten years from time of last entry 3. Minor's records must be kept until patient reaches age of maturity plus period of the statute of limitations

* Use of the medical record in court (2)

1. Improper Disclosure: health care providers and institutions may face civil and criminal liability for releasing medical records without proper patient authorization 2. Subpoena Duces Tecum: written order requiring person to appear in court, give testimony, and bring information described in subpoena

* Two common forms of charting

1. POMR- problem-oriented medical record includes, chronological record of each visit 2. SOAP- subjective, objective, assessment, plan - subjective statements of patient - objective data such as lab reports, vital signs - assessment or diagnosis - plan of treatment

* Contents of the medical record (8)

1. Personal information about patient 2. Clinical data or information -Records of medical examinations -X-rays -Lab reports -Consent forms -Referrals: PT/OT -Prescriptions and refills

* Alcohol and drug abuse patient records (3)

1. Public Health Services Act protects patients who are receiving treatment for drug and alcohol abuse 2.Person or program that releases confidential information relating to these patients is subject to criminal fines 3. Exception if patient should require emergency care

* Privacy act of 1974 (3)

1. agency may maintain only information relevant to its authorized purpose 2. citizens have right to gain access to records and to copy records if necessary 3. applies only to federal agencies and government contractors

Chapter 9- The Medical Record- * The medical record (4)

1. all written documentation relating to patient 2. includes: - past history - current diagnosis and treatment - correspondence relating to patient (communication) 3. is a legal document 4. may be subpoenaed

- personal information include

1. full name 2. address 3. phone number 4. birth 5. marital status 6. employer 7. insurance information

* Completeness of entries (2)

1. medical record needs to document type and amount of patient care that was given 2. in eyes of the court, "if its not documented, it wasnt done"

* Timeliness of documentation (3)

1. medical records must be accurate and timely 2. all entries must be made as care occurs or as soon as possible afterward 3. should be completed by physician within 30 days following patient's discharge from hospital

* Confidentiality (3)

1. medical records should not be released to a third party without patient's written consent 2. only specific records requested should be copied and sent 3. taking photos or other visual images of patient without consent is invasion of patients privacy

* Release of information (4)

1. never send entire medical chart unless it is requested 2. do not send original 3. record may not be released to patient without physician's permission 4. patient must sign release form for information to be sent to insurance company

- what are the exceptions to release medical records

1. parents of minor children 2. legal guardian 3. an agent (power of attorney_ 4. emancipated minor

2. includes

1. past history 2. current diagnosis and treatment 3. correspondence relating to patient

* Contents of the medical record

1. physicians and healthcare professionals notes

* Ownership (5)

1. physicians or owners of healthcare facility, own the medical record 2. patient have legal right of privileged communication and access to records 3. patients can be given a copy of their medical record 4. patients must authorize release of records in writing 5. Doctrine of professional discretion: - physician may determine, based on his or her best judgment, if patient with mental or emotional problems should view medical record

* Purpose of the medical record (4)

1. record of patient from birth to death 2. document for continual management of patient's health care 3. provides data and statistics 4. tracks ongoing patterns of patient's health

3. clinical data include

1. records of medical examinations 2. x rays 3. lab reports 4. consent forms 5. referrals: pt/ot 6. prescription and refills

* State open record laws (2)

1. some states have freedom of information laws that grant public access to records maintained by state agencies 2. medical records generally are exempt from this statute

* Reporting and disclosure requirements (2)

1. state laws require disclosure of some confidential medical record information without patients consent 2. reporting and disclosure are duties of the physician

3. is

a legal document

3. should be

accessed on need to know basis

2. reporting

and disclosure are duties of the physician

3. date

and initial change

4. patients must

authorize release of records in writing

- use only ___ or __ ink

blue or black ink, never use pencil or colored ink pens

t or f. patients have the right of privileged communication

confidential information told to their physician and access to their medical records

2. document for

continual management of patient's health cate

2. write

correction above error

3. provides

data and statistics

1. improper

disclosure: healthcare providers and institutions may face civil and criminal liability for releasing medical records without proper patient authorization

1. medical record

document type and amount of patient care that was given

1. never send

entire medical chart unless it is requested

4. do not

erase or use correction fluid

- HIPPA is

federal law that affects the entire population

4. kept in

fire proof locked area

1. some states have

freedom of information laws that grant public access to records maintained by state agencies

2. medical records

generally are exempt from this statute

2. citizens

have right to gain access to records and to copy records if necessary

3. exception

if patient should require emergency care

1. personal

information about the patient

2. patient have

legal right of privileged communication and access to records

1. agency may

maintain only information relevant to its authorized purpose

- what provides data and statistics on heath matters such as births, deaths, and communicable diseases

medical record

3. patients can be given a copy of their

medical record

2. minors records

must be kept until patient reaches age of maturity plus period of the statute of limitations

2. all entries

must be made as care occurs or as soon as possible afterward

- can someone sign for someone else

no

-is billing information a part of the medical record?

no

5. flasification

of medical record is grounds for criminal indictment

1. record

of patient from birth to death

3. may be placed

on microfilm

1. draw

one line through error

4. tracks

ongoing patterns of patient's health

2. clinical data

or information

3. taking photos

or other visual images of patient without consent is invasion of patient's privacy

1. physicians

or owners of the healthcare facility , own the medical record

2. person

or program that releases confidential information relating to these patients is subject to criminal fines

1. data on

patient records can be created, modified, authenticated, stored and retrieved by computer

- who is the only authorized person to permantely add or change a record

physician

5. doctrine of professional discretion

physician may determine, based on his or her best judgment, if patient with mental or emotional problems should view the medical record

1. POMR

problem oriented medical record, includes chronological record of each visit

1. public health services act

protects patients who are receiving treatment for drug and alcohol abuse

1. medical

records must be accurate and timely

2. legally,

records must be stored for a minimum of ten years from time of last entry

2. only specific

records requested should be copied and sent

3. record may not be

released to patient without physician's permission

2. may

rent storage space

1. state laws

require disclosure of some confidential medical record information without the patients consent

2. special

safety measures should be taken to establish personal identification and user verification codes for access to records

2. do not

send original

1. medical records

should not be released to a third party without the patient's written consent

4. patient must

sign release form for information to be sent to insurance company

2. SOAP

subjective, objective, assessment, plan - subjective statements of patient - objective data such as lab reports, vital signs - assessment or diagnosis - plan of treatment

4. may be

subpoenaed

- what serves as a important path for communication between medical personnel

the medical record

3. applies only

to federal agencies and government contractors

- not all health care professionals will chart information on a patients medical record

true

- t of f. the medical record is a document that records both the care and treatment that a patient did and did not receive. the terms medical record and medical chart are used interchangeably

true

- t or f do not record any personal opinions speculations or judgements

true

- t or f if the jury does not see a test or procedure documented, then they tend to assume that it was not done

true

- t or f late entries into the medical chart mean that, even for a brief period of time, the medical record is incomplete

true

- t or f never erase or use a liquid eraser or in any way remove information from a medical chart

true

- t or f, document patient comments such as "i'm all alone" or "i just feel i cant go on" any comments of this nature should be relayed to the physician because they may indicate an emotional problem in addition to the physical one for which the patient is seeking treatment

true

- t or f. if an attorney subpoena for the medical records, only the specific records that are requested such as surgical notes should be copied and sent

true

- t or f. in the case of c ray film, the physician or institution may allow the original to be sent with the stipulation that it be returned

true

- t or f. many healthcare facilities require all employees to sign a confidentiality agreement. failure to honor this agreement can result in dismissal and possible legal action

true

- t or f. normal as well as abnormal findings should be noted in the medical record

true

t or f. medical record is the property of the hospital and should not be removed from the premises unless there is court order

true

t or f. patients must authorize the release of their records in writing

true

t. or f. because the patient does have a legal right to his or her medical record, it is never acceptable to refuse to turn over a copy if the patient has not paid his or her bill

true

1. current records

usually kept within physicians office

1. each state

varies on length of time records must be kept

3. should be completed by physician

within 30 days following patient's discharge from hospital

1. all

written documentation relating to patient

- as a legal document can both the defendant and the plantiff in a lawsuit use the medical record

yes