Health care syestem corrpond-P660025.ppt

Health system

1. Patient and Office
Records
Lesson Plan: MA B1-7

2. 2
Anticipated Problems
What purposes do patient medical records
have?
What safeguards and protocol should be
followed when maintaining, transferring, or
receiving patient medical records?

3. 3
Terms
 admissible
evidence
 compliance
 EMR
 HIPAA
 Joint Commission
 noncompliance

4. 4
Patient Medical Records
Medical records serve as communication tools.
They help maintain continuity of care.

5. 5
Patient Medical Records
Medical records document:
Medical history
Treatment
Progress
Patient compliance
Patient education

6. 6
Patient Medical Records
They are considered legal documents and
admissible evidence in a court of law.
Admissible evidence is any fact, item,
document, or testimonial that is allowed in
court by a judge and that may be used to
support or refute a case.

7. 7
Patient Medical Records
Medical records provide data for quality
assurance, such as by the Joint Commission.
The Joint Commission is an independent,
nonprofit organization that sets performance
standards for quality and evaluates healthcare
organizations by their ability to meet those
standards. Proper authorization should be
secured where necessary.

8. 8
Patient Medical Records
Medical records provide data for research.
Proper authorization should be secured where
necessary.

9. 9
Patient Medical Records
Medical records provide documentation for
billing.
Medical records can serve as tools for patient
education.

10. 10
Maintaining, Transferring, and
Receiving Medical Records
Safeguards and protocol
Physical safeguards
Administrative safeguards
Technical safeguards
Protocol and guidelines
Special situations

11. 11
Physical Safeguards
Doors to offices in which records (electronic or
paper) are kept should be locked.
Cabinets where records are kept
should be locked and fireproof.

12. 12
Administrative Safeguards
Written policies should be in place regarding:
Maintaining and transferring medical records
Employee access to medical records

13. 13
Administrative Safeguards
Employees should receive security awareness
training and HIPAA training.
HIPAA is the Health Insurance Portability and
Accountability Act of 1996 - established guidelines
to protect the privacy and confidentiality of
patient health information, including medical
records.

14. 14
Technical Safeguards for EMR
EMR (electronic medical records)
Password protected
Antivirus software
Transfers marked “confidential”
Care taken to ensure only the intended individual
receives the medical information

15. 15
Protocol and Guidelines
Medical records are property of the healthcare
provider, patients have the right to access/copy
Neat, legible, accuracy documentation is
essential

16. 16
Protocol and Guidelines
Documentation should be done “in due
course” (at the time of the occurrence or as close
as possible)
Patients must sign an authorization for release
of healthcare information in order for
records to be transferred.

17. 17
Protocol and Guidelines
The patient’s compliance or noncompliance
with the physician’s prescribed treatment
should be documented.
Compliance is the degree or extent to which a
patient follows or completes a prescribed
treatment.
Noncompliance is failure or refusal to follow or
complete a prescribed treatment.

18. 18
Special Situations
Married couples—An authorization for release
of information is needed for a spouse or other
family members to receive patient
information.
Divorce—It may be necessary to determine the
legal guardian of a child of divorced parents.
Guardianship may rest with one or both
parents.

19. 19
Special Situations
Death—Assistance should be sought from
one’s supervisor in determining a deceased
patient’s next of kin or a legally appointed
power of attorney.

20. 20
Special Situations
Adolescents/teens—Adolescents 18 and older
are considered adults in most states;
therefore, the records of an adolescent are
confidential unless the patient signs an
authorization for one or both parents to
receive information.

21. 21
Review
Name three purposes for medical records.
Give an example of how medical records
should be physically safeguarded.
What term is used to describe the degree or
extent to which a patient follows or completes
a prescribed treatment.