HEALTHCARE INFORMATION REGULATIONS, LAWS, AND STANDARDS pt 2 Flashcards
(56 cards)
Laws and regulations governing privacy and confidentiality of patient info and record retention/authentication
LEGAL ASPECTS OF MANAGING HEALTH INFORMATION
stored in electronic forms and in diff types of media (digital images)
Patient record
governed by multiple state and federal laws and regulations in addition to those for licensure and certification.
Health care information (patient-specific information)
Authentication
signature on a document
involved burning or shredding
Destruction of records
Address the medical record as
a legal document,
file folder full of info kung san makikita previous HC services na naavail and even medicines and physicians na naghandle
Patient medical record:
“Guidelines for Defining the Health Record for Legal Purposes”
○ Define the legal health record (LHR) as the documentation of the healthcare services provided to an individual in any aspect of healthcare delivery by a healthcare provider organization
American Health Information Management Association (AHIMA)
Documentation of the healthcare services provided to an individual in any aspect of healthcare delivery by a healthcare provider organization.
LEGAL HEALTH RECORD (LHR)
Includes records of care in any health-related setting used by healthcare professionals while providing patient care services, for reviewing patient data, or documenting observations, actions, or instructions.
LEGAL HEALTH RECORD (LHR)
Healthcare services that includes records in any healthcare setting
LEGAL HEALTH RECORD (LHR)
LHR excludes:
Health records that are not official business records of a
healthcare provider organization
Records such as personal health records (PHRs) that are
patient controlled, managed, and populated.
advance directives ○ anesthesia records ○ care plan ○ consent for treatment forms ○ consultation reports ○ discharge instructions ○ discharge summary ○ e-mail containing patient-provider or provider-provider communication
Examples of documentation found in the LHR:
Data from which interpretations, summaries, notes, etc., are derived.
PATIENT-IDENTIFIABLE SOURCE DATA
analog and digital patient photographs for identification
purposes only
○ audio of dictation
○ audio of patient telephone call
○ diagnostic films and other diagnostic images from
which interpretations are derived
○ electrocardiogram tracings from which interpretations
are derived
○ fetal monitoring strips from which interpretations are
derived
○ videos of office visits
○ videos of procedure
○ videos of telemedicine consultations
Examples of patient-identifiable source data:
Patient-identifiable data used for administrative, regulatory, healthcare operations, and payment (financial) purposes.
ADMINISTRATIVE DATA
Patient identifiers, biometrics, medical record (?)
number
Other knowledge source that do not imbed patient data
authorization forms for release of information
○ birth and death certificates
○ correspondence concerning requests for records
○ event history/audit trails
○ patient-identifiable claim
administrative data
Consists of information aggregated or summarized from patient records so that there are no means to identify patients
DERIVED DATA
Majority of states have specific retention requirements for health care information.
● These state requirements should be the basis for the health care organization’s formal retention policy.
RETENTION OF HEALTH RECORDS
When no specific retention requirement is made by the state, all patient information that is a part of the LHR should be
maintained for at least as long as the state’s statute of limitations or other regulation requires.
“Recommended retention standards”
○ state that patient health records for adults should be retained for ___ after the most recent encounter and patient health records for children should be retained until the time the person reaches the ____ plus the time stated in the relevant statute of
limitations.
Ten years
Age of majority
BASED ON AHIMA: (DEstruction gudelines)
Destroy the records so there is no possibility of
reconstruction.
■ Burn, shred, pulp, or pulverize paper.
■ Recycle or pulverize microfilm or microfiche.
■ Pulverize write-once read-many laser disks.
■ Degauss computerized data stored on internal or
external magnetic media (that is, alter the magnetic alignment of the storage media, making it impossible to recover previously recorded data)
Document the destruction.
■ Date of destruction. ■ Method of destruction. ■ Description of destroyed records. ■ Inclusive dates of destroyed records. ■ A statement that the records were destroyed in the normal course of business. ■ Signatures of individuals supervising and witnessing the destruction.
