chapter 23 Health Records Flashcards
who maintains health records
hospitals, ambulatory care facilities, ER and trauma centers, long term facilities, rehab facilities, home care programs, physician practices
promotes effective communication among health care professionals
continuity and quality of care
ensure complete documentation
why health records and health info. management
hard copy
microfilm
computerized
forms
care of patients institutions admin process patient billing and accounting medical education programs research utilization management risk management quality assurance program HIPPA legal requirements follow up care
function of health records department
wrong exam done
allergic reaction
error in medicine
misdiagnosis
loss of revenue
error in data reporting
standards of health records are set by who
TJC (the joint commission)
HFAP(healthcare facilities accreditation program)
who is CMS
center for medicare and medicaid services. they authorize TJC/HFAP to survey medical facilities
if patient care involved must document in record (also known as charting)
health record content
when patient receives diagnostic procedure, contrast, reactions, clinical date, patient history
radiology dept when to chart
radiology information system(history, exam)
hospital information system(insurance, employment)
RIS, HIS
electronic health records
TJC establishes standards
facilities can have their own program
EHR
patient ID
medical history
diagnostic orders
reports
included in EHR
informed consent
consent for treatment
incident report (state facts not opinions)
administration keeps incident reports for legal purpose but it is not included in patients records
health record content
an order or request form to perform procedure
clinical date, history
if medicare does not cover must tell patient(advances beneficiary)
patient report
authentication signature by radiologist
stored in film, file, RIS or PACS and in patients file
health records in radiology
dated
date of exam
date of radiologists signature
authenticated by signature of radiologist
in ink
line thru error, write error, date and sign
“not documented, not done”
requirements of entries
coding of patients
diagnosis and procedures converted to numeric classification
complete and accurate
reimbursement requirements
System for Medicare patients
Federal govt enacted 1983
Hospitals are paid a predetermined rate according to DRG
CMS under HHS controls it
PPS Prospective Payment System
Determines standard care rate for a group
DRG diagnostically related group
Reimbursement in outpatient setting
APC ambulatory patient classification
Numerical coding system to indicate patients DRG diagnostically related group
Revision October 2015
ICD 10 CM
Codes used for outpatient radiology and labs
CPT current procedural terminology
Must be accurate to receive payment or deny
Ranges from 70010 to 79999
Example is cervical spine with contrast 72142
Reimbursement coding
Used for coding specimens
IRD index of radiologic diagnosis
May be used in court
You may be called upon for testimony or deposition
Incorrect billing is fraud must follow regulations
Legal aspects of health records
Must be author of mistake Line out Write error Date, sign Can be amended by patient but original still exists EHR more difficult to fix
Health records correcting or amending
sign statement as student or employer
Refer them to physician with results
Privileged communication in some states
Confidentiality of health records
Must be in writing
Who is receiving info
Patient name, address, date of birth, date, signature, extent of info
May be charged for copies
Consent to release
Used if time is a factor
Required for 3rd party payer
Include confidentiality notice
Sending health records as a fax
Policy against sharing passwords, access codes, key cards Password 7 characters Change frequently Access only info you need Lock out if improper code Access to records is tracked
Health records information security
Have right to access Can be charged for copies Hospitals ask for patient authorization Hospitals can hold back release Don't share images with patient
Patient access to health records
Record kept for 5 years
10 years if no previous record
MQSA mammography quality standards act
Enacted by congress in 1996
Protects inappropriate access
Department of health and human services enforces it
Can be charged civil or criminally if not followed
Health care providers and health plans must follow
HIPPA health insurance portability and accountability act
Any information that can identify a patient. If info not related to treatment must get patient authorization
PHI protective health information
Can we share PHI?
Yes when part of our job
Record of who received patients info, for what purpose, when released
Accounting of disclosure
Determines who may be given info and who may not
TPO treatment, payment, operational needs
Must have security software
Encryption of data
Firewalls
PHI in portable devices
Give name and room number only
If asked over phone about patient
Disposing of patient info
Shred
Form patient signs giving permission for their PHI to be released, who is receiving and what purpose
Authorization form
If you inadvertently over hear or see info about patient that you don’t need to know is termed
Incidental disclosure
Access EHR not involved with patient Stolen laptop/lost, unsecured PHI Posting patient info on social media EOB explanation of benefits sent to wrong guarantor Access own EMR Take pics of injuries Non work related access
Breaches of HIPPA
Can get access to insurance info Confidential info remains confidential Sign new HIPPA form In charge of own medical record Parent listed as having access Parent is advisor
At age 18
Check that policies are followed
Check computers
Check encryption
Periodic audits
Allows judgement call and experience to decide if info can be released if in patients best interest
Can use sign in and call out
Images not violation if anonymous
HIPPA allows
Protects privacy of student education records
Rights to students
Transfer at age 18
Can inspect, review, have school correct
FERPA family educational rights and privacy act
