1. Medical Law and Ethics Medical Records Requirements and
Medical Records Entries
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2. Behavioral Objectives
Identify the governmental and private entities that establish medical records requirements.
List the types of information in a patient record.
Explain why it is important for a record to be complete and accurate.
Discuss the role of CMS with regard to medical records content and retention
Give examples of the information that state law may require in the medical record.
List the sources of law governing medical records retention.
Recommend considerations for medical records destruction policy.
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3. Behavioral Objectives
Illustrate how legibility and accuracy are important to the quality of medical records
Give examples of how entry errors and poor legibility can create difficulties
Discuss the standards that govern the completeness, accuracy, and legibility of medical records
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4. Behavioral Objectives
Define what timeliness means with respect to medical records entries, and the consequences of failing to comply with this standard.
Define auto-authentication and recommend safeguards for the systems.
Discuss how verbal orders affect the quality of medical records.
List the types of errors that occur in medical records entries.
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5. Terms Legal Health Record (LHR) AHIMA Conditions of Participation
Legibility
Auto-authentication
The Joint Commission (TJC)
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6. Medical Records Records that must be kept are established by:
State licensure regulations of the agency
Accreditation standards
Professional association guidelines
Medicare Conditions of Participation
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7. Medical Records What records must be kept determined by: Policies
Type of information included in the records
Length of time the record is to be retained
Proper methods for destruction of the type of record
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8. Types of Data Personal Demographic information Financial
Insurance information
Employer information
Social
Race/ethnicity
Family relationships
Lifestyle
Court orders or other legal documents
Medical
Record of treatment
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9. Complete Medical Record
Documentation of care given to the patient
Plans and evaluates treatment
Improves the quality of care given to the patient
Provides a means of communication between providers of care
May be evidence in professional negligence
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10. Definition of a Legal Medical Record
“the documentation of healthcare services provided to an individual during any aspect of healthcare delivery in any type of organization”
Each organization must provide the guidelines for a legal record according to the needs of their organization
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11. Medial Record Formats Electronic Paper
Hybrid – combination of both paper and electronic
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12. Issues in the Legal Medical Record
Should the following be included in the LMR?
Pop-ups, alerts and reminders in electronic health records
Audio files
Video files
Personal health record (PHR)
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13. Record Retention Determined by: Federal and state laws
Needs of the organization and space constraints
Resources available
Requirements of liability insurance
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14. Statutory Requirements for Retention
Medicare Conditions of Participation
5 years
State Laws
Varies by state
Minors
Age of majority plus a specified period of years
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15. AHIMA Retention Recommendations
Medical records (adults): 10 years after most recent visit
Medical records (minors): age of majority plus statute of limitations
Diagnostic images: 5 years
Disease index: 10 years
Fetal heart monitors: 10 years after the age of majority
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16. AHIMA Retention Recommendations
Master Patient Index: permanently
Operative Index: 10 years
Physician Index: 10 years
Birth Register: permanently
Death Register: permanently
Surgical Procedures: permanently
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17. Destruction of Records
Must be done in the normal course of business
Must be done in accordance with state law
HIPAA requires Business Associate Agreement to protect
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18. Methods of Destruction
Microfilm: pulverized and recycled
Magnetic data: degaussed
Laser disks: pulverized
Paper : burn or shred
Must keep a record of what information is destroyed
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19. Medical Record Entries
Guidelines
Entries should be clear and understandable, in concise language
Ambiguity or illegible records negatively impact the quality of patient care; may lead to suits
Documents all of the care given to a patient
EHR presents some problems with standardization of entries
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20. Medical Record Entries
Guidelines
The record itself represents the billing and reimbursement for the organization
Good medical record entries defend the organization against fraud and abuse:
HIPAA defines fraud as: “knowingly and willfully executing or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain by means of false or fraudulent pretenses, representations or promises, of any of the money owned by or under the custody or control of any health care benefit program.”
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21. Medical Record Entries
OIG (Office of Inspector General) investigates fraud and abuse charges in federal programs
Legible and complete records are required by:
Joint Commission
Medicare Conditions of Participation
Statutes
Professional organizations
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22. Timelines Entries should be made:
When care is given
When observation is made
Within the time limits established by rules and regulations
Physicians have time frames in which they must complete charting; enforcement is difficult
Late entries
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23. Signatures
Each organization must have a policy on who can document in the medical record
Organization must have a policy on each professional’s Scope of Practice
Policy also needed on countersignatures and for whom: house staff, or students
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24. Authentication Requirements HIPAA Security Rule
Integrity of data and signature
Electronic signatures
Joint Commission requirements
Medicare Conditions of Participation requirements
State requirements
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25. Auto-authentication
Physician enters a computer code to sign report before transcription
Physician agrees to review for accuracy within timelines
Problematical with physician timeliness
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26. Verbal Orders Use of verbal orders State laws
Joint Commission requirements
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27. Corrections and Alterations
Types of errors:
Minor
Typographical errors
Significant
Order errors
Omission of information
Variations in state laws
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28. Corrections and Alterations
Proper method for written records:
Draw a single line through the error
Write corrected information
Initial the correction
Enter the date and time the correction was made
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29. Corrections and Alterations
Proper method for electronic records:
Retain original documentation including date and time stamp
Enter corrected information and record the date and the time
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30. Corrections and Alterations
Under HIPAA a patient has the right to request an amendment to their record
The amendment may be denied but the patient must be given an explanation as to why this was denied
If there is a legal issues with the record, consulting an attorney before amending is desirable
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