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/