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Law, Liability, & Ethics For Medical Office Professionals

Sixth Edition

Chapter 7

The Health Record

Objectives (1 of 2)

Define the characteristics and benefits of an EHR

List different types of health records

Identify owner of a health record

Recognize new dimensions of confidentiality with the use of computers for health records

Identify the procedures necessary for release of information from the health record

Objectives (2 of 2)

Determine who has access to health record

Identify the concerns associated with faxing medical information

Define the importance of health record credibility

Follow an acceptable method for making corrections to a health record

Electronic Health Records (1 of 2)

HITECH Act provides:

“authority to establish programs to improve health care quality, safety, and efficiency through the promotion of health IT [information technology], including electronic health records and private and secure electronic health information exchange.”

Meaningful Use

Incentives

Penalties

Electronic Health Records (2 of 2)

Examples of meaningful use:

Prescribing prescriptions electronically

Providing patients with an electronic copy of their health information

Providing clinical summaries for patients for each office visit recording patient demographics

Recording patient demographics

Maintaining an up-to-date problem list of current and active diagnoses

Protecting electronic health information

Generating lists of patients by specific conditions

Sending reminders to patients per patient preference for preventive/follow-up care

Types of Health Records

Integrated Medical Records

Patient is represented by single record that includes all outpatient and inpatient activity

Medical Record of a Non hospital Situation

Identified as a record of medical care given in facility that does retain the patient bodily overnight

Managed Care Plans

Over past few years, have accumulated large amounts of patient care information

Privacy and Privileged Communication

Privacy, in medical setting, involves:

Individual interest in avoiding disclosure of personal matters

Interest in independent decision making

Ownership of the Health Record

A hospital owns all of its records

Records of a physician or professional office practice owned by physician, corporation, or managed care organization

Access to the Health Record (1 of 2)

Hospitals and physicians should have a written policy on file detailing staff procedures for release of patient information

Policy must reflect local statutes and federal law

Health Insurance Portability and Accountability Act (HIPAA) governs

Patient access

Access to the Health Record (2 of 2)

Innocent party in the health record

Release of information

Capacity to consent to release of information

Release forms

HIPAA

HIPAA Act of 1996 directs Health and Human Services (HHS) to adopt standard “data elements” and “code sets” for electronic coding throughout the entire health care industry

All providers of health care are required to participate in these provisions

Fax Transmission of Medical Information

If a faxed message goes astray or is imprecisely handled by receiver, it may cause a breach in the confidential relationship between physician and patient

Patient’s Access to Own Record

Possibility of misinterpretation by patient

A little knowledge can be more dangerous than no knowledge at all

Manage electronic medical records

Release Forms

No oral requests allowed

Requests must be in writing, court order, and subpoena

Credibility of the Health Record

Is the information in the health record believable?

Changes to health record raise suspicions

Delayed filing of laboratory tests

Incomplete or error-filled records

Altered health records

Fabricating health records

Loss or concealment of records

Making changes in records

Acceptable Method of Making Changes in Medical Records (1 of 2)

There are occasions when making a change in a patient’s records is necessary

If change is made while patient is under treatment, records may be accepted as rewritten

Acceptable Method of Making Changes in Medical Records (2 of 2)

Best way to indicate an entry correction:

Leave original recordation intact with single line drawn through entry being corrected

An initialed notation with date and time should be made inside margin indicating that entry was in error

Correction should be entered in record chronologically