Transcript Have You Read YOUR Medical Record?

Have You Read YOUR
Medical Record?
Association for Healthcare
Documentation Integrity (AHDI)
American Health Information
Management Association AHIMA
Your Medical Record
&
Your Personal Health Record
(PHR)
Quality healthcare begins
with you, the patient.
What is a medical record?
 Encounter information from every health-
care provider
 Separate file from each provider
 Used for care and treatment planning
 Legal document
 Means by which patient and insurance
company can verify that services billed
were actually performed
Why should you want to read
your medical record?
 Check for completeness
 Request an amended report if there is an
error and request a copy of the corrected
(amended) report
What is a personal health record?
 A compilation and coordination of all
healthcare encounters that enables
individual providers to provide better care
and continuity of care, i.e., information
collected by the patient from their
healthcare provider(s) compiled and
updated as necessary for immediate access
in case of a medical emergency.
Why would you want a PHR?
Come with me on a imaginary vacation. You
may go anywhere you wish, this is your
vacation……………(presenter to insert a
brief scenario where a PHR could assist
when away from regular health providers)
Why do you need a PHR?
 Completeness of information
 Information scattered among multiple providers
needs consolidation
 Accuracy of information – no guesswork
(medications and dosages, allergies, etc.)
 To provide medical information to new providers
 Better knowledge to assist in your own medical
care
 Better quality of care; better coordinated care
 Medical emergencies
 Continuity of care
As well as….
 Natural emergency or disaster you can’t control
(prime example – hurricane Katrina)
a. Information may be misfiled
b. Fire or flood, etc., can destroy records
c. Older records can be stored in a manner that
may deteriorate over time, i.e., microfilm
d. Records stored on a computer could
potentially be at risk if computer crashes
e. Physicians sell their practices, retire, or even
die
 Traveling with no easy access to regular physician
And don’t forget………
 New medical personnel with whom you
have no relationship
 Records are not kept indefinitely by
providers
Whose information is the PHR
anyway?
 Facility rights
 Patient rights
 HIPAA – Health Insurance Portability and
Accountability Act
Defines healthcare providers’
responsibilities/boundaries and patient
rights
Accessing your medical record –
how to obtain your information
 Contact Health Information Management
(the medical records dept.) in the facility or
physician’s office
 Ask for a release of information form,
complete it and submit
 http://www.myphr.com/
 Start collecting and organizing information
Will you have to pay for copies
of your medical records?
 Presenter to insert their particular state’s
guidelines.
Storing your information for easy
accessibility
a.
b.
c.
d.
e.
f.
g.
h.
Paper
3x5 cards
Jewelry (necklace or bracelet)
Computer
CD
DVD
Thumb drive
Plastic bin kept in one spot so it is easily
grabbed
A final option
 i. Outsource (accomplished by someone
other than you)
– 1. When deciding to outsource, weigh pros and
cons, i.e., rate your own technology savvy
skills, organizational skills, etc.
– 2. What measures have been taken by
outsource choice to keep your personal health
information (PHI) totally secure
– 3. Check references for greater peace of mind
BACK IT UP!!!!
No matter how you decide to store your PHI
be sure you have a backup.
Take your PHR with you to all
medical visits
 If you haven’t seen your primary care
physician (PCP) for 6 months to a year, an
updated medical history will be requested
 Seeing a new physician for the first time,
new health history forms will be requested
Carry card or wear jewelry with
vital medical information
 Medic Alert bracelet or necklace probably
the easiest to access/find during an
emergency. Information contained on that
is limited due to size.
Safe and confidential
 Your PHI is very confidential and it is very
important that you keep it safe and restrict
access to those predetermined by you.
What information should be
contained in your PHR?
 Name, date of birth, address
 Emergency contact(s) information
 Names, addresses, phone numbers and
specialty of healthcare providers
 Health insurance information
 Living wills, advanced health directives, or
medical power of attorney
 Organ donor authorization
 Important events, dates, heredity conditions
in family and social history (history of drug
addiction, alcoholism, etc.)
 Results from a recent physical examination,
illness, hospitalization
 Functional status
MEDICATIONS!!!
 Current medications
Prescription
Nonprescription (over-the-counter and
herbal)
 Medications taken in the recent past
 Special instructions given to you regarding
medications
 Stop and start dates
 Reason for medication use
 Brand name or generic drug
ALLERGIES!!
 Allergies or sensitivities to drugs or
materials (such as latex)
 Food allergies (wheat/gluten, eggs, nuts)
Name of drug stores,
pharmacists, and phone numbers
For safety’s sake, use the same pharmacy
for all your medications (drug interactions
can be spotted immediately, possible
allergies, etc.)
Other important information
 Immunizations and their dates
 Medical equipment used (CPAP machine,
oxygen)
 A list with dates of significant illnesses and
surgical procedures
 Opinions of specialists
 Important test results (angiogram, cardiac
stress test, EKG, etc.)
 Correspondence between patient and
provider(s)
 Chronic conditions such as diabetes, high
blood pressure, etc.
 Eye examinations
 Dental records
 Permission forms for release of information,
operative permits and other medical
procedures
 Copies of correspondence (letters from one
medical provider to another – request a
copy be sent to you)
Checking for accuracy and
completeness of your medical
record
 Read over the data carefully
 Arrange information chronologically for
easy access
 Make sure medications, doctor visits and
tests are up to date
Internet Services (to name a few)
 Microsoft www.healthvault.com
 BSC Healthcare www.myhealthfolders.com
 Google (yet to launch)
Online Service Requirements
 Internet access
 Computer
 Fees (probably yearly)
Possible Risks
 Internet services are not covered by HIPAA
regulations
 Could patients be easy targets of vendors
wanting to sell treatments for ailments
noted in their records?
 Will Congress extend the HIPAA
protections to cover such services?
Where do you start/go for help?
 Forms available on the Internet, pharmacies
and healthcare providers
 AHIMA website www.myphr.com
 Association for Healthcare Documentation
Integrity (AHDI) www.ahdi.org
To your good health!