HEALTHCARE INFORMATION REGULATIONS, LAWS, AND STANDARDS pt 2 Flashcards
Laws and regulations governing privacy and confidentiality of patient info and record retention/authentication
LEGAL ASPECTS OF MANAGING HEALTH INFORMATION
stored in electronic forms and in diff types of media (digital images)
Patient record
governed by multiple state and federal laws and regulations in addition to those for licensure and certification.
Health care information (patient-specific information)
Authentication
signature on a document
involved burning or shredding
Destruction of records
Address the medical record as
a legal document,
file folder full of info kung san makikita previous HC services na naavail and even medicines and physicians na naghandle
Patient medical record:
“Guidelines for Defining the Health Record for Legal Purposes”
○ Define the legal health record (LHR) as the documentation of the healthcare services provided to an individual in any aspect of healthcare delivery by a healthcare provider organization
American Health Information Management Association (AHIMA)
Documentation of the healthcare services provided to an individual in any aspect of healthcare delivery by a healthcare provider organization.
LEGAL HEALTH RECORD (LHR)
Includes records of care in any health-related setting used by healthcare professionals while providing patient care services, for reviewing patient data, or documenting observations, actions, or instructions.
LEGAL HEALTH RECORD (LHR)
Healthcare services that includes records in any healthcare setting
LEGAL HEALTH RECORD (LHR)
LHR excludes:
Health records that are not official business records of a
healthcare provider organization
Records such as personal health records (PHRs) that are
patient controlled, managed, and populated.
advance directives ○ anesthesia records ○ care plan ○ consent for treatment forms ○ consultation reports ○ discharge instructions ○ discharge summary ○ e-mail containing patient-provider or provider-provider communication
Examples of documentation found in the LHR:
Data from which interpretations, summaries, notes, etc., are derived.
PATIENT-IDENTIFIABLE SOURCE DATA
analog and digital patient photographs for identification
purposes only
○ audio of dictation
○ audio of patient telephone call
○ diagnostic films and other diagnostic images from
which interpretations are derived
○ electrocardiogram tracings from which interpretations
are derived
○ fetal monitoring strips from which interpretations are
derived
○ videos of office visits
○ videos of procedure
○ videos of telemedicine consultations
Examples of patient-identifiable source data:
Patient-identifiable data used for administrative, regulatory, healthcare operations, and payment (financial) purposes.
ADMINISTRATIVE DATA
Patient identifiers, biometrics, medical record (?)
number
Other knowledge source that do not imbed patient data
authorization forms for release of information
○ birth and death certificates
○ correspondence concerning requests for records
○ event history/audit trails
○ patient-identifiable claim
administrative data
Consists of information aggregated or summarized from patient records so that there are no means to identify patients
DERIVED DATA
Majority of states have specific retention requirements for health care information.
● These state requirements should be the basis for the health care organization’s formal retention policy.
RETENTION OF HEALTH RECORDS
When no specific retention requirement is made by the state, all patient information that is a part of the LHR should be
maintained for at least as long as the state’s statute of limitations or other regulation requires.
“Recommended retention standards”
○ state that patient health records for adults should be retained for ___ after the most recent encounter and patient health records for children should be retained until the time the person reaches the ____ plus the time stated in the relevant statute of
limitations.
Ten years
Age of majority
BASED ON AHIMA: (DEstruction gudelines)
Destroy the records so there is no possibility of
reconstruction.
■ Burn, shred, pulp, or pulverize paper.
■ Recycle or pulverize microfilm or microfiche.
■ Pulverize write-once read-many laser disks.
■ Degauss computerized data stored on internal or
external magnetic media (that is, alter the magnetic alignment of the storage media, making it impossible to recover previously recorded data)
Document the destruction.
■ Date of destruction. ■ Method of destruction. ■ Description of destroyed records. ■ Inclusive dates of destroyed records. ■ A statement that the records were destroyed in the normal course of business. ■ Signatures of individuals supervising and witnessing the destruction.
Maintain the destruction documentation indefinitely.
True
Joint Commission Hospital Accreditation Manual defines authentication as
“The validation of correctness for both the information itself and for the person who is the author or the user of the information”
Regardless of rules and regulation, we need standard guidelines for e-signs
True (Electronic signatures)
Make sure e-sign has a password so that signature will not be imitated
True
Generally, a provider is required to have a sign stating that
he/she is the only person who has possession of that
signature and only one who can use it
True (Electronic signatures)
Created when the provider enters a unique code, biometric, or password that verifies his or her identity.
Electronic signatures
An individual’s constitutional right to be left alone, to be free from unwarranted publicity, and to conduct his or her life without its being made public.
● Individual’s right to limit access to his or her health care information.
Privacy
The expectation that information shared with a healthcare provider during the course of treatment/healthcare will be used only for its intended purpose and not disclosed otherwise.
Confidentiality
should be one of the important aspects na kailangan maprovide sa patient that would reflect your professional integrity and ethics
Medical Confidentiality
reflect your professional integrity and ethics
Medical Confidentiality
work hand-in- hand to provide safety to patient and employee
Privacy, trust, confidentiality, and security
Philippine AIDS Prevention and Control Act of 1998
All results of HIV/AIDS testing shall be confidential.
RA 8504
provides more avenues on how persons living
with HIV could try to avail diff services and clarifies gray
areas found in the previous RA
RA 11166
Purpose of both: safeguard health of those with HIV
RA 8504 RA11166
Pertains to more equitable financing through major sources like PhilHealth, life insurances, and personal savings
HEALTH FINANCING
Health financing is a
Tax-based budgeting system largely finance public sector and national and local governments deliver those services
social health insurance - financial health insurance protection for the Filipino people.
PHILHEALTH
Financial protection is limited
resulted to a high
household out of the pocket payment
The government pursues universal health coverage
because of the rapid expansion of membership in the
past
5 yrs
Government health expenditure have
increased
FOUR MAIN SOURCES OF FINANCING
- National and local government
- Insurance (government and private)
- User fees/out of pocket
- Donors
Monetary drives for community development
Donors
Increase responsiveness and client satisfaction
HEALTHCARE DELIVERY SYSTEM
Enables all citizens to receive healthcare services when
needed in a cost-effective manner
HEALTHCARE DELIVERY SYSTEM
Dual health delivery system:
public and private sectors
for both diagnosis and treatment
Public (government institution) and private sector
Health facilities
DOH supervises
Governemnt, corporate hospitals, specialty hospitals,regional hospitals
DND runs
military hospital
At the local level (Provincial government) runs
district / provincial hospitals
At the local level (Municipal government) runs
Provides primary health care through rural health units and barangay health center / barangay health stations
Highly urbanized and independent cities provide
both
hospital services and primary care services
Prevention and promotion of health services and other
health-related programs thru
Rural health units
