Transcript Medical Documentation

Medical Documentation
Purpose of Medical Documentation
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Communication with other healthcare
professionals concerning:
◦ Patient’s health status
◦ Patient treatment and planning
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Fosters quality care
Guides decision making processes
Reimbursement
To show progress or lack of progress
Legal reasons
Research purposes
Medical Documentation
Just as important as the actual treatment
rendered to the patient
 Part of good medical care
 If it is not documented – it did not
happen
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Medical Documentation
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Documentation should be done right. It
should be:
◦ Completed in accordance with the standards
of the healthcare facility
◦ Legible
◦ Timely – documented at the time the service
was rendered
Medical Documentation
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Complete and include all pertinent information
such as:
◦ A list of the patient’s problems and complaints
◦ All medications prescribed
◦ Adverse drug reactions and allergies
◦ Patient’s medical history
◦ Lab tests
◦ Treatment plans
◦ Diagnosis and prognosis
◦ Screens and evaluations
◦ Follow up visits
◦ Therapeutic treatments/services
Medical Record
The medical record is a legal document
and can be called into court in cases
involving litigation
 All documentation should be accurate,
complete and consistent with what
happened during the patient encounter.
 It should never be used to inappropriately
generate revenue for the facility or
provider
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Medical Record
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Confidential
◦ Healthcare professionals must uphold the
moral and legal rights of their patients and
responsibility protect their dignity and privacy
◦ Patient privacy must be protected whenever
healthcare professionals are viewing or
documenting in the patient’s medical record
or discussing a patient’s medical information
HIPAA – Health Insurance
Portability and Accountability Act
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Passed into law by Congress in 1996
HIPAA Provisions:
◦ Provides the ability for workers to transfer and
continue health insurance coverage for his/her family
when changing jobs or experiencing a job loss
◦ Reduces health care fraud and abuse
◦ Mandates industry-wide standards for health care
information on electronic billing and other processes
◦ The protection and confidential handling of protected
health information (PHI) when it is transferred,
received, handled or shared in all forms including:
paper, oral, or electronic. Only the minimum health
information necessary to conduct business is to be
used or shared
Patient Rights Under HIPAA
To ask for and receive a copy of their
health records
 To have corrections made to their health
records
 To receive notice of how their health
information may be used and shared
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Patient Rights Under HIPAA
To decide if they want their health
information shared for certain purposes
such as marketing
 To receive a report on when and why
their health information was shared
 To file a complaint with their provider
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Examples of HIPAA Violations
Disclosing potentially identifiable personal
data on social media networks
 Sending sensitive data to unauthorized
persons
 Discussing procedures with patients in
waiting rooms or other public areas
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Examples of HIPAA Violations
Disclosing PHI to 3rd parties on the basis
of subpoenas not accompanied by court
orders
 Withholding medical records of patients
with outstanding balances
 Accessing health records of ex-spouses
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Penalties – Civil Monetary
Tier
Action
Penalty
1
Individual did not know (and would not have known) the
act was a HIPAA violation
$100-50,000, up to max. or $1.5 million for each violation for
identical provisions during a calendar year
2
The HIPAA violation has a reasonable cause not due to
willful neglect
$1000-50,000, up to max. or $1.5 million for each violation for
identical provisions during a calendar year
3
The HIPAA violation was due to willful neglect but
corrected within the required time period (within 30 days
of notice)
$10,000-50,000, up to max. or $1.5 million for each violation
for identical provisions during a calendar year
4
The HIPAA violation was due to willful neglect and not
corrected
$50,000 or more, up to max. or $1.5 million for each violation
for identical provisions during a calendar year
PENALTIES - CRIMINAL
Involving prosecution by the Department of
Justice with imprisonment
Tier
Action
Penalty
1
Unknowingly or with reasonable cause
$50,000 and up to one year
2
Under false pretenses/through deception
$100,000 and up to five years
3
For personal gain or malicious reasons
$250,000 and up to 10 years
Case Discussion
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Utube video:
http://www.healthit.gov/providersprofessionals/dr-andersons-officeidentifies-risk
References
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http://www.healthit.gov/providers-professionals/dr-andersons-officeidentifies-risk
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http://www.ama-assn.org/ama/pub/physician-resources/solutions-managingyour-practice/coding-billing-insurance/hipaahealth-insurance-portabilityaccountability-act.page?
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http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/
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http://www.dhcs.ca.gov/formsandpubs/laws/hipaa/Pages/1.00WhatisHIPAA.a
spx
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http://get.smarter.com/qa/government-politics/examples-hipaa-violationse62d189871a9bb0c?ad=semD&an=google_s&am=broad&o=32252#
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https://kb.iu.edu/d/ayzf
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http://www.hhs.gov/ocr/privacy/hipaa/enforcement/examples/allcases.html#
case7
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http://www.hhs.gov/news/press/2014pres/04/20140422b.html
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https://www.guttmacher.org/pubs/journals/3608004.html
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https://www.hipaa.com/the-reality-of-hipaa-violations-and-enforcement/