Have You Read Your Medical Record?

Have You Read Your Medical Record? Peggy Beck, RHIA, CMT, FAAMT

AAMT/AIHD Established in 1978 – world’s largest professional organization of MTs.

Our Mission? It works to set and uphold standards of practice in medical transcription that ensure the highest level of • Quality • Privacy • Security of Health Information

Why am I here? I am a CMT. • Trained experts who document and maintain medical records. • We know the ins and outs of medical language and do much more than transcribe words. • We check for mistakes and question notes that don’t make sense. • We are an important safety net in our healthcare system. • We are the first line of defense for patients.

Why is accuracy important? Accurate medical records can mean the difference between a correct diagnosis or a missed health problem, a successful surgery or a serious mistake.

Why does it matter than an MT does the records? • When knowledgeable MTs are able to provide careful documentation, health records reflect the patient’s full medical history, making it easier to identify and correct inconsistencies that could compromise future care.

What is a health record? Every time you visit your doctor, hospital or another healthcare provide, a record of your visit is made. This information is then compiled into what is known as your health record. It serves as a: • Basis for planning your care and treatment. • Means by which doctors, nurses and others caring for you can talk to one another about your needs. • Legal document describing the care you received. • Means by which you or your insurance company can verify that services billed were actually provided.

So…who does this record belong to? • The physical health record belongs to your healthcare provider, but the information in it belongs to you! Understanding what is in your health record helps you: • Make sure it is correct and complete. • Know what is being released when you authorize disclosure of information to others. • Provide an accurate health history to all healthcare providers who treat you.

Did you know? • A health record is information about your health compiled and maintained by each of your healthcare providers. • A PHR is information about your health compiled and maintained by you.

Process: • In order to obtain and read a copy of your medical records from a hospital: • Call Health Information Management Department to request • Present Driver’s license • Advised of HIPAA regulations

HIPAA • HIPAA will be disclosed and HIPAA advisement form signed

Process (continued): • Request exact reports or an abstract – includes dictated reports. • Charge per page. • Will be sent to your home.

Then, what do you do? • Check demographics • History of present illness • Historical information • Important test results • Discharge instructions • Living Will • Health insurance information • CHECK FOR ACCURATE CURRENT INFORMATION: • ALLERGIES: Meds, foods, etc. • CURRENT MEDICATIONS: Check names, dosage and frequency of dosing.

REMINDER • GOAL: Accuracy in content.

Making an Addendum • Notify your physician of the error. • Make a typewritten note identifying information that needs to be added. • Make a cover letter. • Send a copy of your cover letter and note to the physician and the Director of HIM.

Continued • Advise that you want the Director to place your note with the original document. • You want written verification that this was done.

Information for caregivers • If you are a caregiver for someone else, do not assume you automatically have rights to that person’s information, even if you are an immediate family member.

To access another adult’s information: • Have the person you are caring for submit written authorization to his or her doctors and healthcare facilities. • In that authorization, the patient should include language that gives permission to release all information regarding treatment and care to you, and/or anyone else the patient wants to have access. • This document might also include the names of people the information should NOT be shared with. You will need to give this authorization to the healthcare facility’s Health Information Department.

In cases of lengthy or permanent incapacity • A legal guardian for the patient may be appointed through court proceedings. • When incapacity is anticipated, a person may grant power of attorney to another person.

In cases of lengthy or permanent incapacity (continued) • Some grant very broad powers to the holder. • Others are limited to specific issues, such as consenting to healthcare.

Common privacy myths • With the federal laws protecting the privacy of your health information, there has been much confusion and misinformation. Here are the truths to some of these common myths.

True or False • Health information cannot be faxed.

True or False • Email cannot be used to transmit health information.

True or False • Healthcare providers cannot leave messages for patients on answering machines or with someone who answers the telephone.

True or False • Your name and location while in the hospital may not be given out without your consent.

True or False • Your healthcare provide must have your approval to disclose your personal health information to another healthcare provider.

True or False • Your doctor cannot discuss your care with your family members.

Go Online for… • Personal health record info • www.ahima.org

Have You Read Your Medical Record?