Transcript Chapter 19 Documentation and Medical Records

Chapter 19
Documentation and Medical Records
HIPAA
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PHI (protected health information)
The Privacy Rule
The Security Rule
Possible consequences of not following
HIPAA regulations
Question
• Which of the following is true about HIPAA?
A. It protects the health care facilities
B. It protects patients
C. It protects the safety of health care
professionals
Answer
• B. It protects patients
• HIPAA Privacy Rule gives patient specific
rights related to medical records
• HIPAA Security Rule requires
administrative, physical, and technical
safeguards be developed by facilities to
protect patient information
Definitions
• Medical documentation
• Medical record
• Charting
Purposes
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Contributes to good patient care
Provides legal protection
Helps ensure regulatory compliance
Improves cost control
Decreases denials from insurance
companies
Characteristics
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Complete with all requested information
Concise and factual
Properly identified
Legible
Correct spelling, terminology, punctuation,
and grammar
Characteristics
• Clearly and objectively expressed
• Findings not duplicated
• Approved abbreviations listed in facility’s
policy used
• Time and date given for all entries
Characteristics
• Signed by proper person
• Completed without leaving empty lines
• Always charted after giving medication or
performing procedure, not in advance
• Written with black or blue ink
Making Corrections
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Draw single line through error
Write in correct information
Note error per facility policy
Date and initial correction
Correct immediately on computer
If discovered later, correct as above
Question
• Which of the following is the recording of
observations and information about
patients?
A. Charting
B. Medical documentation
C. Medical record
Answer
• A. Charting
• Charting
– Recording of observations and information
about patients
• Medical documentation
– Notes and documents that health care
professionals add to medical record
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• A. Charting
• Medical record
– Collection of all documents filed together
– Form complete chronological health history
Medical Records
• Organized per facility policy
• All health care workers responsible to
maintain records per facility policy
• Chronological or source-oriented
Medical Records Content
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History and physical (H&P)
Physician’s orders
Diagnostic tests
Admissions
Surgical procedures
Medical Records Content
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Graphics
Flow sheets
Medication record
Progress notes
Medical Records Content
• Reminder:
– Verify correct form in chart by ensuring
patient’s name on each document
• Each section chronological
• Thinning a chart
• Security of files
Question
• Which of the following is a form used for
specialty needs?
A. Progress notes
B. Graphics
C. Flow sheets
Answer
• C. Flow sheets
• Flow sheets
– Forms for specialty needs
• Progress notes
– Written chronological statements about
patient’s care
Answer
• C. Flow sheets
• Graphics
– Graphed forms for vital signs
Progress Notes
• Primary tool
– Recording, communicating, and coordinating
care of patient
• May include the following:
– Observations
– Treatments
– Patient response
Progress Notes: Formats
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Problem-oriented charting
Narrative charting
Charting by exception
Computerized
Question
• True or False:
– The chief complaint is the reason the patient is
seeking medical care.
Answer
• True
• Chief complaint
– Reason patient seeks medical care
EHRs
• EHR systems can go far beyond core
charting
– Coordination tools
– Information
– Safety tools
– Scanned documents
EHRs
• Can only communicate within same health
care system
Personal Health Record (PHR)
• Recommended for patients
– Due to mobility of individuals
– Frequent changes in providers
– Frequent changes in insurance coverage
• Assists patient to recall events and dates
Personal Health Record (PHR)
• Prevents long delays in requesting
information
• Types of information to include
– Demographics, such as name, address,
contact information, etc
– Emergency contacts
– Name, specialty and contact information of
previous providers
– Insurance provider(s)
Personal Health Record (PHR)
• Types of information to include
– Medical directives, living will, organ donation,
etc.
– General medical information: height, weight,
blood type, vital signs, etc.
– Allergies and drug sensitivities
– Current conditions and date of diagnosis
– Previous surgeries, including date and results
Personal Health Record (PHR)
• Types of information to include
– Medications (prescription and nonprescription)
– Immunizations and when last received
– Any relevant health care visits, such as
hospitalizations, other specialists or therapists
– Pregnancies
– Medical devices
Personal Health Record (PHR)
• Types of information to include
– Foreign travel
– Family history information
Question
• True or False:
– EHRs have about the same capabilities and
limitations as written charting.
Answer
• False
• EHR systems can go far beyond core
charting