Certification Commission for health Information Technology (CCHIT)

A group whose task is to set standards for electronic medical records (EMR) software.

An initiative to standardize computer applications so that they can communicate back and forth.

Small electrical pump that delivers pressurized air through a nasal mask. used to prevent airway from closing while sleeping,leading to sleep apnea.

To demagnetize. A computer reads stored information magnetically. If information is demagnetized (degaussed), the information is scrambled beyond recognition and cannot be read or reconstructed.

Combination of a clients care from multipe sources(in electronic format).

Computerized version of a client's medical chart in a single clinic or facility

A set codes used to identify a clinic visit rendered by a provider

This law extends the Health Insurance Portability and Accountability and Accountability Act (HIPAA) data privacy and security regulations to support business associates,such as billing companies,accounting firms, and others.

A device worn by a client to monitor the electrical activity orrhythm of the heart over a certain period of time.

An organization that gives advice regarding government policies that affect public health

Method of filing data on film using minute images

A charting system,developed by Lawrence L. Weed, MD that is based on client problems

Individually Identifiable health Information that is transmitted ot maintained in any medium including oral statements.

A cleansing or clearing away;refers to the clearing away of old medical records that are no longers being used.

a charting methods using subjective and objective data for client assessment and planning,education,and response

An electronic observance of activity; in medcine,the monitoring of a client's health status

Medical Records

• Medical records can be in either paper or electronic format
• primary goal is proper care and identification of client
• a medical record that is accurate,complete,and concise encourages quality medical care.
• access,retention,and destruction.

Purpose

• Providing a base for mananging client care that includes initiating,diagnosing,implementing,and evaluating.
• providing interoffice and intraoffice communication of client-related data.
• documenting total and complete heath care from birth death.
• allowing patterns to surface that eill alert providers of clients needs
• Serving as a legal basis for evidence in itigation and to protect the legal interests of clients and providers.
• Providing clinical data for education and research.

Medical records creation and content

• A medical record is established at the first encounter between a provider and client
• organization depends on the office policy of the clinic

Documentation

• documentation in the medical record facilitates the diagnosis and treatment of clients,ensures client safety and reduces medical errors,promotes health-care management,and serves as legal documents in risk management issues.
• a medical record should include date,time,details of each encounter,signature of the health-care professional who took a part in the encounter.
• paper charts legible writing is important

• specialist who see a client once may have an abbreviated form.

Problem-Oriented Medical Records

• was developed by Dr. Lawerence L. Weed
• based on clients problems and health-care professionals adds to the chart in a particular place in the same manner.
• identifies the clients problems not simply diagnosis
• A problem could be a condition or a behavior that results in physical and emotional distress or interferes with the clients functioning
• examples include pain in ankle and knees,fear of falling,decreased appetite, even the inability to pay bills

• The problem list is numbered and appears as a checklist sheet
• to identify clients problems the provider explores the cient and performs services that may include anexamination,history,laboratory test,obtaining subjective data from client.
• weed also developed a computerized medical record that permits the healthcare provider to build a computer-based POMR while accessing data

SOAP/SOAPER

• subjective,objective,assessment,and plan,education,response-a method of charting
• subjective includes what the client says,family comments, clients exact words
• objective events that are observed and measured lab test,radiograph,and physical examination
• assessment providers evaluation based on subjective and objective (S+O=A)
• plan treament and actions taken
• 2 additional letters ER
• education education given to client
• response clients understanding of education and care given
• record must be concise,complete,clear, and in chronological order.

Electronic Medical Records

• electronic medical n electronic health records
• as the client acquires service from other sources therefore the EMR becomes EHR as result are compiled in the PCP record

Institute of Medicine

• Health information and data completes client demographics and past medical history including medications and allergies.
• Order management capability of ordering test and prescriptions
• Result Management all testing is computerized and more readily available to the provider
• Decision support information should be accessible to aid a provider in his or her decision making
• patient support instruction sheets and treatment plans readily available for clients
• administrative processes and reporting scheduling billing etc tasks tot interact with medical records so that payment can be realized
• electronic communications and connectivity information would be accessible
• reporting and population health this function would automate mandatory reporting to government agencies

• 2004 George bush outlined a plan to ensure americans electronic health records within ten years
• CCHIT has a certification for 3 years
• 2009 obama signed the american recovery and reinvestment act
• providers advantage to adopt EMR so they can have funds for several years
• stimulus money will no longer be in existence in 2015

guidelines

• computer hardware services, a list of users approved to access medical information,robust firewalls,passwords changed atleast 90 days, passwords are secure and hidden, computer station will limit the number of tries,computer screens out of view, screen savers are used to prevent unwanted viewers
• update information
• safety for client
• better client care
• efficiency and savings
• savings are realized by the use of templates for visits and reduced time needed for transcriptionist

Legal aspects of the medical records

• medical record is considered a legal document
• these types of records protect cient and provider
• HIPAA-clients must grant written consent or permission to disclose their PHI
• Health information technology for economic and clinical health is the the law that extends the HIPAA data privacy
• this allows states to prosecute any peron dealing with or  in the healthcare field where they have access to files

release of information

• is signed by a client and gives provider authority to release medical documents.
• if a client is a minor a parent may sign
• if separated the parent with sole custody of minor must sign all release forms
• if client is incompetent then legal guardian signs consent
• if deceased then representative of estates signs consent
• The necessity of using a medical court record in court emphasizes the importance of accurate records that honestly reflect the clients course of treatment

Errors in medical records

• handwritten error can only be fixed in 2 ways draw line through error using a red pen, write correction or error then initials, indicate date and write in correction
• eectronic error use word processing software, a line through the error,correction placed behind the information you put a line  through,intials and date added tdo document
• poor alterations can be detrimental to the providers defense

Subpoenas

• if healthcare professional and the record are subpoenaed is called subpoena duces tecum
• notified in writting the provider and client and allow 14 days for a response.
• the person or agency issuing the subpoena pay the cost of photocopies

Telecommunications

electronic mail

• it provides communication among providers and their employees and between provider and client.
• it creates a written record that information was shared,allows embedding of educational links,and can be used in malpractice suits to exhibit communication
• email is not private

fax machines

• a fax machine is useful but their are negative points to that for example
• the fax could be sent to te wrong destination and retrieved by an unauthorized person
• guidlines use fax machine when there is not enough time for more secure measures such as mailing
• use the ones in restricted access areas
• client authorization
• verify the recipient of fax
• document the reason for the fax transmission

Ownership of medical records

• the accepted rule is that medical records are the property of the person creating them and entering data.
• clients may be expected to make an appointment to obtain copy and pay reproduction fees.
• clients who request their medical records must to do it in writing.
• orignal copy is retained in the clinic and request honored with a photocopy of a complete record or summary

Storage of Medical Records

• EMR software being used determines the back-up process and storage requirements
• closed or inactive files are those of clients no longer being seen
• active records shoud be in the readiness for providers

Retention of Medical Records

• records should be retained until the statue of limitations for acts of medical malpractice has expired so that the reords are avaliable for litigation
• hospital medical records and provider medical records have different retention time limits
• professionals must know the limits for the state in which they are employed

Destruction of Medical Records

• once limits of retention are reached procedures have to be followed to purge aged data
• a destruction log is developed to keep track of all destroyed medical records
• log must include date and method of destruction a statement and the signature of the persons who witnessed the destruction
• one method of destruction is picking an service that specializes in destruction

• upon completion of the task, a signed certificate is returned to the clinic indicating the contents and date of destruction
• on site destruction- a truck is fitted with an industrial shredder arrives at the clinic and records are placed into the shredder and destroyed
• American health information management association feels like the preferred method is to degauss the data
• This is a techiqnue that alters the way data align in the magnetic storage field and renders the previous data unrecoverable and impossible to reconstruct
• The AHIMA also recommends reassessing the process annually based on current technologies accepted practices and availability of timely and cost-effective destruction services 

Multiple choice

1 who owns medical records? The providerT

2 a privacy nootice should address the following topics? restrictions, request of confidential information,request of any amendment to the PHI, opportunity to recieve an accounting of PHI diclosures

3 which of the following is not a purpose for medical records? protects only the legal interest of the provider

4 weeding out inactive charts that are older than their retention time frame is called? purging

5 POMR is an acronym that stands for ? problem-oriented medical records

True/false

1. True- regardless of the storage medium in which a medical record is saved in active charts should be protected with the same safety measures as active charts.

2. false-in all cases medical records should be kept for a minumun of 5 years

3.True- proper and complete documentation is a providers best defense against litigation

4.false- as long as a client signs a medical record release form the health-care professionals can make copies of record without providers approval

5.false faxing of medical records is preferred over mailing a copy of records