Medical Documentation

Purpose of Medical Documentation Communication with other healthcare professionals concerning: Patient’s health status Patient treatment and planning Fosters quality care Guides decision making processes Reimbursement To show progress or lack of progress Legal reasons Research purposes

Medical Documentation Just as important as the actual treatment rendered to the patient Part of good medical care If it is not documented – it did not happen

Medical Documentation Documentation should be done right. It should be: Completed in accordance with the standards of the healthcare facility Legible Timely – documented at the time the service was rendered

Medical Documentation Complete and include all pertinent information such as: A list of the patient’s problems and complaints All medications prescribed Adverse drug reactions and allergies Patient’s medical history Lab tests Treatment plans Diagnosis and prognosis Screens and evaluations Follow up visits Therapeutic treatments/services

Medical Record The medical record is a legal document and can be called into court in cases involving litigation All documentation should be accurate, complete and consistent with what happened during the patient encounter. It should never be used to inappropriately generate revenue for the facility or provider

Medical Record Confidential Healthcare professionals must uphold the moral and legal rights of their patients and responsibility protect their dignity and privacy Patient privacy must be protected whenever healthcare professionals are viewing or documenting in the patient’s medical record or discussing a patient’s medical information

HIPAA – Health Insurance Portability and Accountability Act Passed into law by Congress in 1996 HIPAA Provisions: Provides the ability for workers to transfer and continue health insurance coverage for his/her family when changing jobs or experiencing a job loss Reduces health care fraud and abuse Mandates industry-wide standards for health care information on electronic billing and other processes The protection and confidential handling of protected health information (PHI) when it is transferred, received, handled or shared in all forms including: paper, oral, or electronic. Only the minimum health information necessary to conduct business is to be used or shared

Patient Rights Under HIPAA To ask for and receive a copy of their health records To have corrections made to their health records To receive notice of how their health information may be used and shared

Patient Rights Under HIPAA To decide if they want their health information shared for certain purposes such as marketing To receive a report on when and why their health information was shared To file a complaint with their provider

Examples of HIPAA Violations Disclosing potentially identifiable personal data on social media networks Sending sensitive data to unauthorized persons Discussing procedures with patients in waiting rooms or other public areas

Examples of HIPAA Violations Disclosing PHI to 3rd parties on the basis of subpoenas not accompanied by court orders Withholding medical records of patients with outstanding balances Accessing health records of ex-spouses

Penalties – Civil Monetary Tier Action Penalty 1 Individual did not know (and would not have known) the act was a HIPAA violation $100-50,000, up to max. or $1.5 million for each violation for identical provisions during a calendar year 2 The HIPAA violation has a reasonable cause not due to willful neglect $1000-50,000, up to max. or $1.5 million for each violation for identical provisions during a calendar year 3 The HIPAA violation was due to willful neglect but corrected within the required time period (within 30 days of notice) $10,000-50,000, up to max. or $1.5 million for each violation for identical provisions during a calendar year 4 The HIPAA violation was due to willful neglect and not corrected $50,000 or more, up to max. or $1.5 million for each violation for identical provisions during a calendar year

Penalties - Criminal Involving prosecution by the Department of Justice with imprisonment Tier Action Penalty 1 Unknowingly or with reasonable cause $50,000 and up to one year 2 Under false pretenses/through deception $100,000 and up to five years 3 For personal gain or malicious reasons $250,000 and up to 10 years

Case Discussion Utube video: http://www.healthit.gov/providers- professionals/dr-andersons-office- identifies-risk

References http://www.healthit.gov/providers-professionals/dr-andersons-office- identifies-risk http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing- your-practice/coding-billing-insurance/hipaahealth-insurance-portability- accountability-act.page? http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/ http://www.dhcs.ca.gov/formsandpubs/laws/hipaa/Pages/1.00WhatisHIPAA.a spx http://get.smarter.com/qa/government-politics/examples-hipaa-violations- e62d189871a9bb0c?ad=semD&an=google_s&am=broad&o=32252# https://kb.iu.edu/d/ayzf http://www.hhs.gov/ocr/privacy/hipaa/enforcement/examples/allcases.html# case7 http://www.hhs.gov/news/press/2014pres/04/20140422b.html https://www.guttmacher.org/pubs/journals/3608004.html https://www.hipaa.com/the-reality-of-hipaa-violations-and-enforcement/