Ch 8 Patient Record Requirements

generally define a medical record.

A document that contains complete and accurate description of a patient's history, condition, diagnostic and therapeutic treatment and the results of that treatment.ur

Why is the health record subject to stringent legal requirements?

because it is the legal document of the care and treatment of the patient. The medical record is used to prove what did - or did not - happen. If it is not documented then it was not done. The medical record is the major piece of evidence in any legal case involving medicine.

why shouldn't another physician sign for a physician even if they are in practice together?

because proper Foundation for admitting a medical record into evidence requires that the record be made by a person with knowledge of the acts, events, conditions, opinions, or diagnoses appearing with in. Allowing a physician to sign for another physician can raise questions concerning the "reliability and integrity" of the medical record.

why are the laws governing health records reference only the paper format?

because that is how they were originally written, and with how fast technology has changed, the laws cannot be updated that quickly. Therefore, any laws reference paper medical records apply to medical records in electronic format.

Why are the accreditation standards used frequently in malpractice cases? Do they have the force of law?

because they have the most detailed standards for documentation content of medical records. They do not have the force of law.

lists ways the medical record serves nonclinical purposes.

billing and reimbursement verify disabilities legal record of care and treatment

how should an error be corrected in an electronic health record.

by adding an addendum to the record. Usually you can mark the entry as an error and then add an addendum in the system and electronically sign it. There is usually a reference or link to the erroneous documentation within, at or near the addendum.

who promulgates regulations?

executive agencies

if a physician wants to use a rubber stamp in the health records, what must he/she do?

he/she must request to use a rubber stamp and the use must be permissible by the local licensing authority. the practitioner must sign a statement that the stamp is in his/her sole possession and that they will not delegate its use to anyone else.

are there many statutory provisions which address the content of health records?

no

Does one federal law address the legal requirements governing all patient records?

no it is more like a patchwork of federal and state laws together.

what are the steps a healthcare facility should take to comply or not comply with the patients wishes, if he/she wants to have their records amended?

patient must request an amendment in writing to the institution. health care institution must decide to grant or deny the request for the amendment. patient must be notified of the decision to amend or not amend and the reason why. amendment, or denial of the request for amendment, must be placed in the patient record. If the amendment is made, then copies of the amendment must be provided to anyone else who may have already received a copy of the erroneous original documentation.

what do record retention policies cover?

policies cover the length of time medical records must be maintained by the healthcare provider and when the records can be destroyed and how.

does the health record have a role in direct patient care?

yes

does the medical record serve both clinical and nonclinical uses?

yes

is the medical record a legal document?

yes

can a patient request that his/her records be amended? what law allows for this?

yes, HIPAA allows for this in the final privacy rule

Are rubber stamps acceptable under the CMS Conditions of Participation?

CMS no longer allows rubber stamps as a method of authentication in patient records. this means that any hospital receiving Medicare funding cannot allow the use of rubber stamps.

what are the two most widely recognized voluntary accrediting bodies in healthcare?

The Joint Commission (JC) and the Healthcare Facilities Accreditation Program (HFAP).

define deeming authority

The substitution of complying with the requirements and standards of an accrediting organization in lieu of complying with the Medicare conditions of participation issue by CMS.

describe a hybrid health record.

a health record that is part paper-based and part computer-based.

who establishes professional guidelines? how are the guidelines used?

allied health professional organizations publish guidelines that address the existence and content of health records. they are used to address sensitive legal issues related to medical records. AHIMA establishes professional guidelines for HIM professionals which are found in the position statement and the practice brief documents.

what is the difference between authentication and authorship?

authentication confirms the content of the entry by either a written signature, initials or an electronic signature (e-sig) code. authorship identifies the healthcare provider who has made the entry. It identifies the chicken-scratch mark as the signature of a provider (signature list).

what happened in the case Henry by Henry v St Johns Hospital?

child was born with cerebral palsy, supposedly because of the use of an inappropriate amount of anesthesia. At trial, it became clear that the physician who has administered the anesthetic had changed the entries made by the nurse concerning the amount of anesthia given. The court recognized that normally a physician would not write on or correct a nurses note. because the physician had altered the entry of another healthcare professional, it created an inference that the physician was attempting to cover up information was therefore liable for negligence.

list other ways the medical record helps serve clinical purposes?

communication between clinical disciplines. tool for doing concurrent and retrospective analysis and are relied on by the medical community for research purposes. assist the public health community in identifying incidences of diseases and help them to control the disease and monitor the overall health status of a population. assist in quality improvement activities.

what is the difference between concurrent and post-discharge review?

concurrent chart review takes place while the patient is still in the hospital. The patient record is reviewed for missing documentation or result. In post-discharge review, the HIM department staff conduct the review after the patient has been discharged.

List the additional information that the medical record contains.

detailed personal info medical info financial info social data about patient.

how should an error be corrected in a paper health record?

draw a single line through the erroneous entry so it is still legible write the word "error" next to the lined-out documentation and include the date, time and initials of the person correcting the documentation write the correct documentation near the error, or write why it is being lined-out only the person who made the error can correct the error never completely cover up the error. it is considered "hiding" something never use white-out or liquid paper.

why should the record be complete? are there regulations/standards governing complete records?

if it is not documented, it was not done. Complete medical records also prevent tests from being repeated and assure correct information is avaliable for clinicians to make decisions and provide quality patient care. Incomplete records can impair research as well. Complete medical records are needed for a provider to present a good defense in a lawsuit.

how did the court case of Collins v. Westlake Community hospital and Hurlock v. Park Lane Medical Center support the theory "if it wasn't documented ; it wasnt done"?

in both cases nursing staff were reportedly only documenting "by exception" in the patient records. in other words, they only documented treatment when there was an abnormal finding. In both cases, there was no documentation in the records, it was implied that the follow-up checks and the proper amount of turning did not occur.

explain how the medical record (in the most basic sense) serves the healthcare environment.

it is the chronological documentation of clinical care given to a patient. It is a business record and a communication tool.

how long does the COP (conditions of participation) require facilities to maintain health records.

records should be retained for as long as the states applicable statute of limitations. If the state does not have a statute of limitations regulation, then the COP recommends medical records be kept for 5 years after discharge.

compare and contrast record destruction done in the ordinary course of business with that done due to closure of an entity?

records that are destroyed in the ordinary course of the healthcare business usually have to do with the time frame of how old the records are. Compared with Destruction due to a closure which may (or may not) have been planned and closure records will fall under different guidelines and state rules. Closing facilities will usually also need to contact the appropriate licensing authority before destroying records. Records destroyed in the ordinary course of business are done so as specified by their written policies, whereas closure records are subject to state and/or federal guidelines for destruction. both situations command strict confidentiality procedures to prevent accidental or incidental release/disclosure of patient information.

how long is the retention period recommended by the AHA?

retention for 10 years from the date of the last encounter with the physician/clinician.

how long is the retention period recommended by the AHIMA? how does the AHIMA address records of minors in regards to retention?

retention of medical records for 10 years for adult patients from the date of the last encounter/visit (outpatient or inpatient). for minor patients, AHIMA recommends the records be kept until the patient reaches 18 plus the statute of limitations period governing medical malpractice lawsuits for that state.

why should a physician stay current in documenting into the health record?

so that complete information is documented in the correct patient record while events are fresh in the physicians mind.

list the sources which supply requirements for maintaining health records.

statutory provisions regulations (federal and state level) Accreditation standards institutional standards professional guidelines

what affects the functions and uses of the health record?

statutory provisions regulations (federal and state level) accreditation standards institutional standards professional guidelines

Between both the federal and state levels what do regulations cover in regard to the health record?

that a health/medical record shall be maintained a broad listing of the content requirements for medical records Specific, detailed provisions governing the content.

identify the special procedures involved with the destruction of alcohol and drug abuse records upon a programs closure.

the HIM professional should examine federal regulations governing these areas to determine how to proceed with destruction. The healthcare provider will have to obtain the patients written authorization before transferring records to another provider or treatment programs the transfer is not authorized, then the records are to be sealed and stored until the appropriate state regulated destruction date.

identify the importance of keeping permanent evidence of a records destruction in the ordinary course.

the certificate of destruction is a providers proof that the records were destroying in accordance with the facility policies and not due to any malicious reasons.

What is the biggest challenge to compromising the integrity of electronic health records?

the cut, copy and paste features of any electronic environment. Cut, copy and paste can complicate the concept of who authored the entry in the medical record.

what is the backbone of virtually every professional liability actions and why?

the medical record and the documentation within it. memories are short. Clinicians can read a medical record to remember the patient and the treatment and outcomes.

who should be the only one authenticating a health record entry?

the practitioner who wrote the documentation or dictated the information for transcribing.

What does contemporaneously mean?

to happen at or near the same time as the event. Documentation by clinicians should be done as near to the time of the occurrence as possible. Timeliness in documentation is critical to quality patient care.