Record-Keeping Procedures Flashcards
Patient Records
Who mandates the legality of patient record-keeping? How long are patient records to be maintained at pharmacies?
- OBRA and State mandated
- All Rx drug orders within past 2 years (preceding most recent entry)
Patient Records
What is to be contained at a minimum for patient record compliancy?
- Full name of patient
- address/phone number of patient
- Age/DOB of patient
- Gender
- All Rx drug orders within past 2 years at that pharmacy
- Comments relevant to patient/drug therapies
Patient Records
What is obtained as “necessary patient information”?
- Allergies
- Drug Reactions
- Idiosyncrasies
- Chronic conditions / disease states
- Other medications, including OTCs
Confidential Information
When and to whom may confidential information be released?
- Patient
- Practitioners and pharmacists where, in the pharmacist’s professional judgement, release is necesary to protect the patient’s health and well-being
- Other persons or governmental agencies authorized by law to receive such information
HIPAA
What does HIPAA stand for? What is HIPAA’s intent?
- Health Information Portability & Accountability Act
- Assure security & privacy of patients’ medical records, while allowing the flow of PHI to provide high quality health care
Confidential Information
Confidential information is priviledged information maintained in a patient’s record or which is communicated to a patient as part of patient counseling
True or False
True
HIPAA
Under HIPAA, every health care provider who transmits health information is a covered entity
True or False
True
HIPAA
What entities and records fall under HIPAA?
- Rxs, patient record systems (Rx profiles), recorded RPh comments relevant to patient therapy
- Pharmacies and all Medical Facilities - all have HIPAA Privacy Officer
NPI requirement implemented for private info being de-identified
HIPAA
To whom do patients report perceived HIPAA violations?
DHHS Office for Civil Rights
HIPAA
How should patients be notified of their rights and how their health information may be used?
- Consents to release information
- How to access information
- How medical information may be disclosed to each other
HIPAA
How should HIPAA privacy notices be documented?
- Document by signed statement or log book
- Person named in insurance policy can represent family
- No requirement for future signatures
- Maintain records of these notices for 6 years from date of signature or last date of Rx dispensed
HIPAA
How long must privacy notice documents be maintained?
Maintain records of these notices for 6 years from date of signature or last date of Rx dispensed
Confidential Patient Records: Pharmacy Perspective
Patient records may only be released to whom?
- Patient
- Pharmacist/personnel authorized to handle Rx
- Prescriber/authorized personnel
- Legal personnel (BOP inspectors, DEA inspectors)
Use professional judgement necessary to protect health & wellbeing
Confidential Patient Records: Pharmacy Perspective
Can a spouse of a patient see their medication profile or receive a copy of an Rx?
- Theoretically, not without a written statement from the patient granting authority
- Picking up Rxs is under pharmacist judgement - unnecessary for patient to give written permission
Confidential Communication
What are confidentiality recommendations for patient refill reminders & consultations?
- Refill reminders - keep drug name/use private
- Minimize likelihood of accidential disclosure to surrounding people
- Minimal information given on phone calls & answering machines
