Table of Contents  Protect patients and their personal health information  Became law in 1996

Table of Contents  Personal information, such as full name, phone number, address, work number and address, birth date, social security number, and marital status  Medical history  Description of symptoms  Diagnoses  Treatments  Prescriptions and refills  Records of patient’s telephone calls  Name of legal guardian  Name of power of attorney  Notes about copies of medical records

Table of Contents  Medical records belong to health care providers, but patients have the right to see and obtain a copy of their records.  Patients with mental illness may not have the right to see their medical records.  If a patient’s employer or prospective employer pays for a job-related physical examination, the employer, not the patient, has the right to see and obtain a copy of the records.

Table of Contents  Medical records must be complete, legible, and timely.  All information in records must be objective and the information must be initialed and dated.  Errors should never be erased or covered with correction fluid. Instead, a single line should be drawn through an error so that the error is still readable.

Table of Contents  Advantages: ▫Instant access ▫Remote access to up-to- date information ▫Simultaneous access ▫Decreased time to record information ▫Legible ▫Better organization ▫Flexible data layout ▫Automated checks and reminders ▫Increased privacy and decreased tampering, destruction, and loss due to required authorization

Table of Contents  Disadvantages: ▫Additional hardware, software, and licensing costs ▫Resistance to giving up paper records ▫Difficult data entry ▫Training ▫Computer downtime, such as unexpected failure or routine servicing ▫Confidentiality and security concerns, such access of information to unauthorized individuals

Table of Contents  Limit individuals who have access to records by using passwords, fingerprints, voice recognition, and eye patterns.  Require codes to access specific information.  Place monitors in areas where others cannot see the screen.  Do not leave monitors unattended while confidential information is on the screen.  Do not send confidential information by .  Back up data.  Constantly monitor and evaluate the use of electronic medical records.

Table of Contents  Printers: ▫Do not leave printers unattended while printing confidential information. ▫Do not print confidential information on printers that are shared by unauthorized individuals. ▫Do not print confidential information on wrong printers. ▫Make sure to collect printouts of confidential information from printers. ▫Do not throw unneeded printouts of confidential information in trash cans. Instead, these should be shredded.

Table of Contents  Copiers: ▫Do not copy confidential information if unauthorized individuals are in the area and can see the information. ▫Do not leave copiers unattended while copying confidential information. ▫If a paper jam occurs, be sure to remove the copies that caused the jam from the copier. ▫Make sure to collect all copies of confidential information as well as the original from the copier. ▫Do not throw unneeded copies of confidential information in trash cans. Instead, these should be shredded.

Table of Contents  Telephones: ▫Do not use patients’ names if unauthorized individuals are in the area and can overhear. ▫When leaving messages, simply ask patients to return the call. Do not speak about any confidential information.