1. Medical Documentation

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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
$ ,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

14. 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

15. Case Discussion
Utube video: professionals/dr-andersons-office- identifies-risk

16. References
identifies-risk
your-practice/coding-billing-insurance/hipaahealth-insurance-portability- accountability-act.page?
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