What is any document that relates to the care and treatment of a patient?
What is a permanent or long lasting account of something?
Are letters from PTs to physicians included in medical records?
What are three things that are NOT part of the medical record?
1. Business Records
2. Billing Information
3. Incident Reports
What does a complete, well documented medical record function to do?
1. Improves patient care
2. Improves reimbursement for providers
3. The best defense to a suit or claim
4. Improves learning
What are three record keeping requirements of the federal government (Medicare, Medicaid, and prisoners) medical records?
1. Procedure was actually performed
2. Procedure was medically necessary
3. Procedure was performed competently
What are three parts of a utilization review?
1. Did the patient respond well?
2. Was there something better we could've done to improve outcomes?
3. Was it efficient patient care? (i.e. order, timeframe)
What is the record keeping requirement of State Law?
What is the process of obtaining informed consent?
1. Assess DMC
2. Explain Alternatives and Risks
3. Explain that it is VOLUNTARY
4. Pt. understands what might happen if they REFUSE treatment
Who owns the medical record?
Facility - but everyone has access to it
What is the statute of limitations for normal people?
What is the statute of limitations for pediatric patients?
2 years after their 12th birthday
How long do the feds have to come back and review records?
At least 5 years
What is the "federal floor" for medical confidentiality rules?
What are 4 exceptions that have STRICTER guidelines than HIPAA?
Drug or alcohol records
Treatment of Minors
What are examples of when you break confidentiality?
Incapacitated Adult Abuse
Births and Deaths
Medical Examiner Cases
Responding to licensing board about
When would you can give out HIPAA information without written authorization?
Treatment of patients
Health Care operations
What is anything that identifies the patient and/or their condition?
Protected Health Information
-oral, written and electronic communication
Is information that has been de-identified protected?