HIM 226 Chapter 8

baxuvovi's version from 2016-10-14 23:50

Section 1

Question Answer
Requirements that affect the function and uses of health record.1. statutory
2. regulatory
3. accrediting
4. institutional
Define health record content.characteristics essential to constitute an adequate health record
Define heath record.document that contains a complete and accurate description of a patient's history, condition, diagnostic and therapeutic treatment, and the results of treatment
List clinical uses of health record.1. direct patient care
2. chronological document of clinical care
3. method of cross discipline education
4. research activities
5. public health monitoring
6. quality improvement activities
List nonclinical uses of health record.1. billing and reimbursement
2. verify disabilities
3. legal document of care
Compare & contrast clinical uses with secondary purposes of a health record.1. clinical uses
a. chronological record of a patient's care
b. method of communication for current and subsequent episodes of care
c. research and quality improvement activities
d. health records are used by clinicians
2. nonclinical uses
a. billing function
b. legal record of a patient's care
c. documentation to support a claim of disability
d. health records are used by nonclinicians
Define hybrid record that is part paper based and part electronic
Define legal health record generated at or by the healthcare provider or organization that addresses the patient's episode of care that was delivered by the provider or organization

Section 2

Question Answer
How does a health record serve as a legal document?1. record of a particular episode of a patient's care
2. used to prove what did or did not happen in a particular case
3. to establish whether the applicable standard of care was met
List source of law that addresses legal requirements of health record.1. statutory
2. regulatory
3. accrediting
4. institutional
5. professional guidelines
Define statutory provisions.1. federal or state laws
2. municipal codes
3. no one federal law address the legal requirements governing all patient records
Define regulations.power regulated to executive agency to promulgate rules/regulations
2. example of regulation is condition of participation governed by Dept. of Health and Human Services
Define accrediting not have force of law standing alone & frequently used to establish that standard of care in negligence actions against health care providers
Define deeming authority.compliance with the requirements and standards of both accrediting organizations may substitute for compliance with the federal gov't Medicare Conditions of Participation for Hospitals published by CMS
List accrediting bodies.1. Joint Commission
2. American Osteopathic Association's Healthcare Facilities Accrediting Program
3. DNV Healthcare
4. National Committee for Quality Assurance (NCQA)
5. Commission on Accreditation Rehabilitation Facilities (CARF)
6. Community Health Accreditation Program (CHAP)
7. Accreditation Association for Ambulatory Healthcare (AAAHC)
8. National Commission on Correctional Healthcare (NCCHC)
9. American Correctional Association
10. College of American Pathologists (ACP)
Who does Joint Commission accredit?1. hospitals
2. behavioral health facilities
3. critical access hospital
4. longterm care facilities
5. homecare facilities
6. transplant centers
7. ambulatory care centers
8. clinical laboratories
9. disease specific care programs

Section 3

Question Answer
Who does American Osteopathic Association's Healthcare Facilities Accreditation Program accredit?1. hospitals
2. behavioral health facilities
3. critical access hospitals
4. primary stroke centers
5. substance abuse centers
6. rehabilitation facilities
7. ambulatory care center
Who does DNV Healthcare accredit?hospitals
Who does National Committee for Quality Assurance?managed care association
Who does Commission on Accreditation of Rehabilitation Facilities accredit?program & service in medical rehabilitation; assisted living; behavioral health; adult day care; employment and community service
Who does Community Health Accreditation Program accredit?homecare organizations
Who does Accreditation Association for Ambulatory Healthcare accredit?ambulatory care services
Who does National Commission on Correctional Healthcare accredit?correctional institution
Who does American Correctional Association accredit?correctional institutions
Who does College of American Pathologists accredit?clinical laboratories

Section 4

Question Answer
What does AHIMA publish in regards to professional guidelines?position statements and practice briefs regarding health record content
Define authorship.identifies the healthcare provider who has made the entry, either in writing, by dictation, by keyboard, or by keyless data entry
Define authentication.content of the entry, either by written signature, initials, or computer-generated signature code
Can you cut, copy, and paste with EHR, why or why not?no, can misidentify who is making the entry; can document in wrong record; add services when services not rendered; inadvertently repeating entry no longer accurate
Is rubber stamping acceptable?maybe prohibited; CMS no longer accepts the use of these stamps in health record documentation instead uses signatures that are handwritten, electronic, or facsimiles
Is it legally proper for a physician in a group practice sign medical entries made by another physician?no; authentication principles dictate that only the author of the entry may authenticate the entry; the exception would be where specific accreditation standards or regulations allowed for this action
Why is there a need for timeliness for health records?delivery quality patient care and required as condition for both licensing and accreditation
Why is there a need for completeness for health records?health care provider's ability to render quality patient care and conduct research and education is impaired

Section 5

Question Answer
What is the proper method to correct a paper base health record?draw a single line thru entry and write "error" next to it, along with date, time, and initial of person making correction
In a correction, should you still be able to read the original entry?yes
What is the proper method to correct a EHR?an addendum is added to the electronic health record reflecting the correction; original document/entry is not altered, but a computer code attribute is used to reference the original document to the addendum
What does deleting data do?compromises the integrity of the record and impacts the trustworthiness of the record for evidentiary purposes
Should deletion be permitted?only in rare instances, deleted data should be recoverable if necessary
Explain the concept of an amendment to the record under the HIPPA Privacy Rule.provides patient with a right to amend patient specific health info & sets a minimum standard to follow in allowing amendments to health record by a patient. This rule requires the healthcare provider to respond to patient that it has made the requested amendment or if the amendment is not made give written notice to the requestor.
Define record retention policy.general principles determining the length of time, health data, and the health record, in which those data are stored must be maintained by the healthcare provider
What forces influence retention of health info?1. certain statutes and regulation provide specific requirement on record retention
2. render continuing patient care
3. conduct education and research
4. defend a professional liability action
5. storage constraints
6. new technology
7. fiscal concerns

Section 6

Question Answer
What is a record retention schedule?a document that details what data will be retained, the retention period, and the manner in which the data will be stored
What is Virginia statue of limitation on record retention?2 yrs
Under Medicare Condition of Participation what is there statue of limitation on hospital health records?if there is no statue of limitation for that state then 5 yrs after discharge
What is HIPAA statue of limitation on record retention?covered entities must retain records showing compliance for period of 6 yrs
Which business records should be retained?books of accounts, vouchers, cancel checks, personal and payroll documents, sale records, compliance documents, and correspondence
What is AHIMA retention period?1. recommends a 10 yr retention period on adult patient records measured from the date of the patient last encounter
2. for minors, retaining records until the patient reaches the age of majority + the statue of limitations
What is AHA retention period?suggest a 10 yr retention period for clinical records measured from the date of the patient last encounter
What does the enterprise content and record management addresses?1. electronic records management principles (all of the digital and analog records)
2. enterprise content management principles (technology, tools, methods to capture, store, deliver, and preserve content across enterprise)
3. retention of data and records is managed systematically
4. streamlines response to e-discovery requests

Section 7

Question Answer
List the 3 types of destruction for health records.1. destruction in ordinary course
2. destruction due to ownership
3. destruction due to course
Explain record destruction policies.1. controlling statues and regulations may specify or recommend the method of destruction
2. types of destruction are shredding, burning, or recycling
3. some laws may also require the hospital to create an abstract of patient data before destroying patient records
Explain HIPPA Security Rule for destruction.1. paper records can be dissolve in acid, burning, pulverizing, or shredding
2. electronic media destruction may include magnetic degaussing, overwritten of data, and destruction of backup tapes or other backup media
Define certificate of destruction.document that shows what data and records destroyed, who destroyed data and records, and method used for that destruction
What is the consequence of not having a certificate of destruction?opens the healthcare provider to a charge that an individual record was destroyed for suspicious reasons such as to gain an advantage in lawsuit
Explain destruction due to ownership change.contractual agreement should address what happens to records due to sale of entity, retirement, or death
What happens with destruction due to closure?1. state laws vary
2. transfer to another provider or deliver to state authority
Discuss alcohol/drug abuse with the destruction due to care providers are required to obtain the patient's written authorization before transferring records to an inquiring program or another program named in the authorization

Section 8

Question Answer
Explain Ravenis v. Detroit General Hospital.1. case of incomplete record
2. two patients received cornea transplant from cadaver, developed ophthalmitis and lost sight
3. incomplete record on cadaver missed an acute infection
4. hospital failed to maintain complete records; jury found hospital liable for medical malpractice
Explain Collins v. Westlake Community Hospital.1. Court ruled negligence for no documentation because a nurse failed to follow doctor's orders to record observations of patient's toes
2. his leg was in a cast, had to have toes amputated
3. Nurse stated she always checks, but only records abnormal findings
4. therefore since not recorded, the checks did not happen.
Explain Hurlock v. Park Lake Medical Center.1. Nurse, again failed to follow doctor's orders to turn a parplegic patient every 2 hours to avoid bed sores
2. Patient developed many ulcers causing leg to be amputated.
3. The record showed the patient had only been turned 18 times
4. if orders had been followed properly, there should have been 117 entries recorded documenting pt. had been turned.
5. Court inferred from the record that the pt. was not turned.
Explain Ahrens v. Katz.1. case of incorrect way to make correction to a medical record.
2. nurse used correction fluid (white out).
3. testimony at trial indicated that the use of correction fluid to make correction to the record was not in accordance with correct nursing practices
Explain HENRY v. ST JOHN's HOSPITAL.1. Child was born with cerebral palsy, do to inappropriate amt of anesthesia.
2. A physician corrected a nurses' notes in the record.
3. The court inferred that because another healthcare worker made a correction to the nurse's entry, that the nurse was trying to cover something up / conceal something.
4. The MD was liable for negligence.
Explain Bondu v. Gurvich.1. case of unavailability of a health record to define a lawsuit.
2. husband died of heart attack during administration of anesthesia as part of heart surgery
3. wife sought copies of health record & discovered it was lost or destroyed
Explain Carr v. St. Paul Fire & Marine Insurance.1. case of destruction of record in ordinary course of business
2. treated at emergency dept, sent home & died>br>3. records could not be producted
4.civil liability