1. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 1

2. 2 Part 3 Legal and Ethical Issues Central to Health Information Management

3. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 3 Chapter 8: Patient Record Requirements

4. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 4 Introduction Health information may be kept in different formats: –Paper health record or chart –Electronic health record (EHR) –Abstract of patient information Health record is legal record of care Subject to stringent legal requirements

5. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 5 Health Record: Functions and Uses Health record is a document that: –Describes patient’s history, diagnoses, therapies, and results of treatments –Includes personal, medical, financial, and social data about the patient –Serves both clinical and non-clinical uses –Is a chronological document of clinical care –Is created at the time care is given –Is used by providers to communicate with each other about the patient’s care

6. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 6 Health Record: Functions and Uses Additional clinical uses of records are: –Research activities –Public health monitoring –Quality improvement activities Non-clinical uses of records include: –Billing and reimbursement –Verification of disability –Legal document of care

7. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 7 Legal Health Record Traditionally paper based Today, growth in electronic records and hybrids (part paper/part electronic) Regardless of medium, business record –Generated at or by the health care provider or organization –Addresses the patient’s episode of care

8. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 8 Content of the Health Record Various sources supply requirements

9. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 9 Content of Health Records: Statutory Provisions Federal, state, or municipal codes Patchwork of laws on the subject Generally limited to requirement that health care provider must create a record Some state statutes do define content –Usually in context of hospital licensing –Tennessee Medical Records Act of 1974

10. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 10 Content of Health Records: Regulations Power delegated to executive agency to promulgate rules/regulations State and federal regulations may –Generally require that health record be kept –List broadly the content requirements –Detail specific provisions for content Some states adopt CMS requirements Others adopt accreditation standards (JC)

11. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 11 Content of Health Records: Regulations Example of specific detail in regulation: –CMS Conditions of Participation The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services... Must be legible, complete, dated, timed and authenticated in written or electronic form by the person responsible for providing or evaluating services 42 CFR § 482.24 (2009)

12. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 12 Content of Health Records: Accrediting Standards Do not have the force of law Do establish standard of care Voluntary accrediting bodies –Joint Commission (JC) –AOA Healthcare Facilities Accreditation Program (HFAP) –Det Norske Veritas (DNV) –National Committee for Quality Assurance

13. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 13 Content of Health Records: Accrediting Standards Some states adopt standards as regulatory requirements Deeming authority –Compliance with accreditation requirements and standards –May substitute for compliance with federal CMS Conditions of Participation Accreditation also enhances reputation. Standards include requirement to maintain health record

14. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 14 Content of Health Records: Other Standards Institutional standards –Health care institutions may create own or adopt accreditation standards –Guide health care content for institution –Do not carry the force of law Professional guidelines –Address existence and content of records –Publish practice statements and practice briefs (AHIMA) –Helpful to health information manager

15. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 15 Health Records: Timely and Complete All records must be –Authored: identity of provider who made entry In writing By dictation, keyboard, or keyless data entry –Authenticated: confirmation of content By signature, initials, or code Implies that entry is accurate

16. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 16 Health Records: Timely and Complete Authorship complications related to EHR –Ability to cut, copy, and paste may compromise integrity of records –Risk for misidentification of author or misfiling of patient information –Policies/procedures to reduce risk are essential Rubber stamp signatures –May be prohibited (CMS does not allow) CMS accepts physician signatures that are –Handwritten, electronic, or facsimile

17. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 17 Health Records: Timely and Complete Only the author of entry may authenticate The record must be reliable –Made by person with first-hand knowledge –Made at or near the time of the actual occurrence of event (contemporaneous) Reliability is critical for –Delivery of quality care –Meeting licensing and accreditation requirements –Admission of record into evidence in legal action

18. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 18 Health Records: Timely and Complete Incomplete record –Impairs quality of patient care –Impairs provider’s defense against lawsuit –May violate laws and accreditation standards Role of health information management –Concurrent and post-discharge chart reviews –Identify and attend to deficiencies If it wasn’t documented, it wasn’t done

19. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 19 Health Records: Timely and Complete Mistakes happen Corrections to a paper-based record –Draw a single line through the error –Write “error” beside it, date, time, and initial –NEVER obliterate, white out, or cover up error –Only the person who made error should correct it Corrections to an EHR –Same principles, different system –Addendum to record with reference to original entry –Standards organizations have issued guidelines

20. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 20 Health Records: Timely and Complete Providers rely on information in the record: –Never delete data from record –Deletion compromises integrity of record Corrections of the record by the patient: –Under HIPAA, the patient has a right to request an amendment to record –If entity agrees to request, inform patient and insert amendment –Provider may deny request for limited reasons –State laws may also establish patient rights

21. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 21 Health Records: Retention Record retention policies determine –Length of time heath records are stored –Form of storage: paper versus imaging or electronic form –Timing of EHR transfer to archival database Record retention schedule details –What data will be retained –The retention period –Manner in which data is stored

22. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 22 Health Records: Retention Statutes and regulations –Some states establish time frame for retention –Usually related to death or discharge of patient –CMS requires retention for period of state’s statute of limitations or 5 years after discharge Influence of statute of limitations –Health care provider: ability to defend a lawsuit may depend on access to record –Hospital negligence: loss or destruction of records before time period in which patient can sue

23. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 23 Health Records: Retention Other health care business records –Accounting and payroll –Compliance and quality related documents –Sales records and correspondence Business record retention policies also needed –Based on statutes and regulations (HIPAA) –Include all forms of media: paper and electronic

24. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 24 Health Records: Retention Retention of records of HIPAA compliance –Audit and monitoring results –Internal investigations and hotline reports –Employee training –HIPAA requires retention for a period of 6 years AHIMA/AHA recommend retention for 10 years –Adult patient records from date of last visit –Additional concerns related to children; retain to age of majority plus statute of limitation period

25. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 25 Health Records: Retention EHR and new technology –Less physical storage space needed than for paper charts –Storing massive amounts beyond required period makes search and production difficult. Policies should address –Process for creating and retrieving data –What information will be stored –Reasonable retention period

26. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 26 Health Records: Retention How long should records be retained? –No one answer –Period specified under statute or regulation Also consider –Medical and administrative needs –Cost constraints –Technology and Storage constraints Policies should be realistic, practical, and tailored to the needs of the organization

27. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 27 Health Records: Retention Potential for increased costs for legal discovery process Enterprise Content and Record Management (ECRM) –Systematic approach to e-discovery requests –Addresses both content and management principles Technology and tools used by enterprise Methods to capture, store, deliver, and preserve Views all data from an enterprise perspective

28. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 28 Health Records: Destruction Policies should follow controlling statutes or regulations –Method of destruction –Creation of abstract of data before destruction –Patient notification requirements HIPAA security rule –Requirements for effective information security –Cover issue of destruction of PHI

29. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 29 Health Records: Destruction Method must be specified in policy –Paper: shredding, burning, or recycling –Electronic media: Magnetic degaussing or overwriting data Destruction of back-up tapes or other media Timing: after retention period has expired Certificate of Destruction (COD) –Retain permanently as evidence –When, by whom, and how records were destroyed

30. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 30 Health Records: Destruction HIPAA privacy rule –Maintenance of confidentiality is paramount –Civil fines and punishment for breach Contracts with commercial vendor –Method of destruction –Safeguards to be followed to maintain privacy –Indemnification if unauthorized disclosure occurs –Certification that destruction was properly done

31. © 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 31 Health Records: Destruction Reasons for destruction 1.In the ordinary course of business 2.Ownership change –Due to sale of entity, retirement, or death –Health data and records are property assets –Contractual agreement should address what happens to records 3. Due to Closure or Dissolution of Practice –State laws vary –Transfer to another provider or deliver to state authority –Special federal regulations for addiction related care –If bankruptcy, federal law provides guidance