1. Comprehensive Medical Assisting, 3rd Ed Unit Two: Fundamentals of Administrative Medical Assisting Chapter 8 – Health Information Management: Electronic and Manual

2. The Health Insurance Portability and Accountability Act of 1996
Goals
Simplify claims and accelerate reimbursement
Provide better access to insurance when changing jobs
Regularize employer funding
Facilitate and protect electronic communications
Protect communications between the physician and insurer

3. The Health Insurance Portability and Accountability Act of 1996
Covered Entities – Insurance plans, clearinghouses, and providers using electronic billing, transfers, and medical records
Administrative simplification – Electronic transactions, privacy, security, national identification
Designated compliance staff
HIPAA officer
Privacy officer

4. Releasing Medical Records
HIPAA – “PHI” (Protected Health Information)
Any information linked to a specific person
Covered entities must
Share PHI for health purposes only
Provide the minimum necessary
Adopt written procedures
Designate a privacy officer and train employees
Release of any records must be authorized by the patient or the patient’s legal guardian

5. Releasing Medical Records
Releasing Records to Patients
Patients have the right to see and receive a copy of their medical records
Patients age 17 years and younger must have a signed consent from their parent or guardian
The physician decides what to copy

6. Proper Authorization for Release of Medical Information

7. Standard Medical Records
Information must be
Easily retrievable
Kept in an orderly manner
Complete
Legible
Accurate
Brief

8. Standard Medical Records
Medical records should include
Chief complaint
Present illness
Family and personal history
Review of systems
Progress notes
Radiography, laboratory, and consultation reports
Medications administered
Diagnosis or medical impression
Physician’s or assistant’s ID and signature
Documented advance directives
Correspondence

9. Sample Page From Patient’s Chart

10. Electronic Medical Records
May include demographic and practice data only or the complete chart
Pros
Legibility
Easy storage and retrieval
Mandatory, error- trapped data entry
Diminished need for paper and storage space
Cons
Downtime and equipment failures
Cost
Security issues
Increased need for training

11. Electronic Medical Records
Security
Need-to-know access
Firewall
Secure remote backup
Password protocols
Confidentiality policy, training, and discipline
Must include all PDAs, laptops, and PCs

12. Medical Record Organization
Formats
Narrative – least structured
SOAP – subjective, objective, assessment, plan
POMR – problem-oriented medical record
Keyed to the patient’s specific medical problems
Four components: database, problem list, treatment plan, progress note
Every provider encounter must be documented

13. Documentation Forms Printed forms and charts Save space and time
Facilitate retrieval
Medical history forms
Flow sheets
Progress notes

14. Medical Record Entries
The medical record should be complete, accurate, and legible
Document every patient visit
Document every external communication
with patients
with third parties
Include original documents
Transcribe or “shingle” for standard-size paging

15. Workers’ Compensation Records
These records belong to the employer
Open a new chart even for an existing patient
Maintain data alongside, not in, the existing chart
Exclude information not directly impertinent
Previous health and family history
Maintain the record for 2 years after the last date of treatment
Obtain verification before treating

16. Storing Medical Records
Medical Record Preparation
Establish a routine
Replace worn folders and labels
Keep track of location with an “outguide” or barcode system
Filing Procedures
File daily to keep charts current
Scan and shred to electronic records
Condition, index, sort, and store hardcopy records

17. Filing Systems Alphabetic Filing
By “unit” (e.g., last name, first name, middle name)
If all units are the same, use the birthdate
Can be supplemented with color coding
Numeric Filing – isolate a cross-reference index for confidentiality
Six digits usual – may be read as
single digits
pairs
pairs in reverse order (terminal digit filing)
Other systems for non-patient records

18. Storing Health Information
Electronic Data Storage
Backup daily to a safe, fireproof, remote location
Backup may be “hot” or inactive
Storage of Standard Medical Records
Shelf files with side labels
Drawer files – more convenient but use more space
Rotary circular or lateral files – use the least space

19. Storing Health Information
Classification of Records
Active – patients seen within recent years – store for easiest access
Inactive – patients not seen recently – store out of the way
Closed – patients who have terminated relationship – store on microfilm or microfiche

20. Record Retention
Records must be kept until the statute of limitations has tolled
Records should be kept permanently if feasible
Records in closing practices should be released to patients

21. End of Presentation