Comprehensive Guide to HIPAA Documentation and Medical Records

1. Chapter 19 Documentation and Medical Records

2. HIPAA • PHI (protected health information) • The Privacy Rule • The Security Rule • Possible consequences of not following HIPAA regulations

3. Question Which of the following is true about HIPAA? It protects the health care facilities It protects patients It protects the safety of health care professionals

4. 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

5. Definitions • Medical documentation • Medical record • Charting

6. Purposes • Contributes to good patient care • Provides legal protection • Helps ensure regulatory compliance • Improves cost control • Decreases denials from insurance companies

7. Characteristics • Complete with all requested information • Concise and factual • Properly identified • Legible • Correct spelling, terminology, punctuation, and grammar

8. Characteristics • Clearly and objectively expressed • Findings not duplicated • Approved abbreviations listed in facility’s policy used • Time and date given for all entries

9. 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

10. Making Corrections • 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

11. Question • Which of the following is the recording of observations and information about patients? • Charting • Medical documentation • Medical record

12. Answer • A. Charting • Charting • Recording of observations and information about patients • Medical documentation • Notes and documents that health care professionals add to medical record

13. Answer • A. Charting • Medical record • Collection of all documents filed together • Form complete chronological health history

14. Medical Records • Organized per facility policy • All health care workers responsible to maintain records per facility policy • Chronological or source-oriented

15. Medical Records Content • History and physical (H&P) • Physician’s orders • Diagnostic tests • Admissions • Surgical procedures

16. Medical Records Content • Graphics • Flow sheets • Medication record • Progress notes

17. 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

18. Question • Which of the following is a form used for specialty needs? • Progress notes • Graphics • Flow sheets

19. Answer • C. Flow sheets • Flow sheets • Forms for specialty needs • Progress notes • Written chronological statements about patient’s care

20. Answer • C. Flow sheets • Graphics • Graphed forms for vital signs

21. Progress Notes • Primary tool • Recording, communicating, and coordinating care of patient • May include the following: • Observations • Treatments • Patient response

22. Progress Notes: Formats • Problem-oriented charting • Narrative charting • Charting by exception • Computerized

23. Question • True or False: • The chief complaint is the reason the patient is seeking medical care.

24. Answer • True • Chief complaint • Reason patient seeks medical care

25. EHRs • EHR systems can go far beyond core charting • Coordination tools • Information • Safety tools • Scanned documents

26. EHRs • Can only communicate within same health care system

27. 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

28. 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)

29. 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

30. 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

31. Personal Health Record (PHR) • Types of information to include • Foreign travel • Family history information

32. Question • True or False: • EHRs have about the same capabilities and limitations as written charting.

33. Answer • False • EHR systems can go far beyond core charting