Health Care Law and Legislation, Statistics Policies

Helpm31990

9781284538588_SLID_CH11.pptx

Home >Nursing homework help >Health Care Law and Legislation, Statistics Policies

Medical Records

Chapter 11

LEARNING OBJECTIVES

Describe the contents of medical records.

Explain the ownership and who can access a patient’s medical record.

Desciribe the importance of maintaining complete and accurate records.

Describe the advantages and disadvantages of electronic records.

Explain what is meant by the medical record battleground.

Medical Record Means of Communication

Documentation of a patient's

Illness

Symptoms

Diagnosis

Treatment

Planning tool for patient care

Document communication (e.g., progress notes)

Medical Record Means of Communication – II

Protect legal interests of patient, org, & practitioner

Provide database for use in statistical reporting

Continuing education

Research

Provide info necessary for 3rd-party billing

Ownership & Release of Records

Ownership: Provider of Care

Request by Patients

Right to access

Failure to Release

Ownership & Release of Records: Privacy Exceptions

Requests: 3rd Parties

insurance carriers (for processing claims)

medical research

educators

government agencies

Criminal investigations

Substance abuse records

Completion of Medical Records Records Must Be:

Legible

Accurate

Timely Written

Cases:

Failure to Record Patient’s Care

Failure to Use Information

Timely Completion of Medical Records

Privacy Act of 1974

Enacted to safeguard individual privacy from the misuse of federal records

Provide individuals access to records

concerning themselves that are maintained by federal agencies

to establish a Privacy Protection Safety Commission.

HIPAA

Health Insurance Portability & Accountability Act of 1996

Act to protect the privacy, confidentiality, & security of patient information.

HIPAA KEY Provisions

Patients able to access their record & request correction of errors.

Patients must be informed of how personal information will be used.

Patient consent for release of info for marketing purposes required.

Patients can ask insurers & providers to take reasonable steps to ensure their communications are confidential.

Documentation of Treatment

Continuing patient care

Case: Accuracy of Medical Record Entries

Retention of Records

Necessary to provide continuing patient care.

Retention requirements can vary state to state.

Case:

Destruction of Oncology Records

Failure to preserve a patient’s records can lead to lawsuits.

Electronic Records Advantages

Timely access to patient information

patient demographics

problems lists

history & physical exams

vital signs

diagnostic test results

consultant reports

Electronic Records Advantages II

Order entries

Medications

Critical alerts

out-of-range test values

drug–drug & food–drug interactions

computer-assisted diagnosis and treatment

reminders for follow-up testing

assistance in standardizing treatment protocols;

Electronic Records Advantages - III

Improving ability to timely share information with treating providers

Improved productivity & quality

Reduced charting costs

Support for clinical education & research

Generation & transmission of electronic prescriptions

Storage of medical records indefinitely

Electronic Records Disadvantages

Risk of lost confidentiality

Unauthorized disclosure of information.

Increase in cyber crime.

HITECH

Health Information Technology for Economic & Clinical Health Act

designed to promote widespread adoption & interoperability of health information technology.

Requires reporting of unsecured protected health information that affect 500 or more individuals.

Medical Record Battleground

Record should be complete & accurate

Not a tool for registering complaints between caregivers

Legal Importance of Records Case Studies

Records Authorship Questioned

Communications Between Caregivers: Failure to Note an Order Change

Medical Identity Theft

Falsification of Records

Documentation Falsified

False Entries in Operative Report

Objection to Record Notations

Tampering with Records

Erasures and Write Overs

Rewriting and Replacing Notes

Illegible Handwriting

Medical errors because of poor handwriting can lead to extended length of hospital stays & death in some cases

Harvard study found “penmanship was among the causes of 220 prescription errors out of 30,000 cases

Case: Fatal Handwriting Mix-Up

Confidential & Privileged Communication

Cases:

Release of Confidential Information

Breach of Physician-Patient Confidentiality

Ordinary Business Documents

Attorney-Client Privilege

Joint Commission Reports Privileged

Charting & Helpful Advice

Complete & pertinent entries

Timely entries

Legible entries

Clear & meaningful entries

Complete

Charting & Helpful Advice - II

Avoid

defensive & derogatory notes

erasures & correction fluids

criticism

complaints

tampering with the chart

Charting & Helpful Advice - III

Secure records pending legal action

Obtain legal advice

Entries made by others must not be ignored.

patient care is a collaborative interdisciplinary team effort.

Entries made by health care professionals provide valuable information in treating the patient.

REVIEW QUESTIONS – I

What are basic purposes of medical record?

Discuss advantages & disadvantages of computer-generated medical records.

Medical record is sole property of the hospital & should never be released. Discuss your opinion on this statement.

How long should patient records be maintained?