...The patient health record contains important information regarding clinical quality and care. The health record is also undergoing a radical evolution as more imaging becomes available and digital record keeping becomes the norm. The HIM professional needs to have a clear understanding of how to manage increasingly complex sources of health information. In this paper, we will discuss how the HIM professional should manage the use of paper forms in a hybrid environment in order to maintain the integrity of the health record. We will also compare the strengths and weaknesses of using hybrid records and discuss legal issues that may arise when using hybrid records. Additionally, we will evaluate the “Willow Bend Record Policy” to determine if it protects health information for record storage and destruction of paper and electronic health records based on Kansas state regulations, Medicare Conditions of Participation, and Health Insurance Portability and Accountability Act (HIPAA). The term hybrid health record is used in today’s healthcare environment to describe a format that has both paper based and electronic information. Given that this type of health record is complex in content, it comes with additional requirements in regard to management. This is particularly true when comes to managing patient information into a concise, presentable formation. As HIM professionals, we should also be seeking ways to improve access to information and balancing that access with security....
Words: 1601 - Pages: 7
...Legal and Ethical Considerations in the Implementation of an Electronic Medical Record (EMR) Marcia Stevenson |General Purpose: |The history of EMR | |Specific Purpose: |To learn about the legal and Ethics requirements of an EMR | |Central Idea: |To educate the audience that EMR has been updated to reflect current trends, practices, | | |standards and legal issues | | | | | | | Ethical issues related to electronic health records (EHRs) confront health personnel. Electronic health records create conflict among several ethical principles. Electronic health records may represent beneficence because they are alleged to increase access to health care, improve the quality of care and health, and decrease costs. Research, however, has not consistently demonstrated access for disadvantaged persons, the accuracy of EHRs, their positive effects on productivity, nor decreased...
Words: 578 - Pages: 3
... Administrative Ethics Paper Health care is among the most personal services rendered in our society today however to deliver this care a large amount of personnel must have access to intimate patient information. Maintaining confidentiality is becoming more difficult. The need to protect patient confidentiality is evident in legal restrictions imposed by state laws and the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA) and was recently amended under the Health Information Technology for Economic and Clinical Health Act.(politifact, 2011). Physicians have always had a duty to keep their patients confidence. This means that a physician or any administrative person may not disclose any medical information revealed by a patient or discovered by a physician in connection with the treatment of a patient. As explained by AMA’s Council on Ethical and Judicial Affairs the purpose of a physician’s ethical duty to maintain patient confidentiality is to allow the patient to feel free to make a full and frank disclosure of information to the physician with the knowledge that the physician will protect the confidentiality nature of the information disclosed. (AMA, 2009). Maintaining patient confidentiality is a legal duty as well as an ethical duty. A physician’s legal obligations are defined by the US Constitution, by federal and state law and regulation, and by the courts.(AMA, 2011). Despite these ethical and legal obligations, access to confidential...
Words: 855 - Pages: 4
...Angela Cicchetti HIM 4/28/14 The storage and destruction of hybrid charts Angela Cicchetti HIM 4/28/14 The storage and destruction of hybrid charts Hybrid Records The use of a hybrid chart can be beneficial and yet at times it can be a liability if it is not looked after and stored correctly and efficiently. Hybrid charts are used in paper and computer format. The hybrid chart can be very useful and it also holds potential for liability if not stored correctly. The paper hybrid chart can be stored in a few different ways but it is up to the office manager to choose which method is the most efficient, effective and holds the less chances of liability for the healthcare facility. There are three processes that are implemented when storing a hybrid chart. These processes are creation and identification, storage and retrieval, and retention and disposition. As long as these three processes are integrated in the storage and usage of hybrid charts then the charts will be effective and protected from liability at the same time. The best charting system for the paper part of the hybrid chart depends on how big the organization and facility are that are filing and storing these paper charts. Smaller healthcare facilities use an alphabetical or numerical charting system to find the paper charts fast and efficiently. The larger healthcare facilities use more advanced chart filing systems such as a unit number system where the patient receives one number that...
Words: 1257 - Pages: 6
...February 6, 2012 MEDICAL RECORD PROCEDURES HEARTLAND HEALTH COMMUNICATIONS Volume 2 Kelley Auxier Heartland Health Communications Revised February 7, 2012 Table of Contents Heartland Health Communications……………………………..1 Table of Contents……………………………………………………….2 Mission Statement……………………………………………………...3 Objectives………………………………………………………………….3 Chapter 1……………………………………………………………………….4 Purpose and Function of a Health Record……………………………………..4 * Patient care management * Financial and administrative processes * Patient self-management Maintenance of the health record………………………………………...5 What is a medical record used for………………………………………..5 Who can document in the chart…………………………………………..6 Chapter 2………………………………………………………………….7 Medical Record Department Responsibilities…………….........................7 Medical Record Departments major functions……………………………7 Retention of Medical Records…………………………………………..8-9 Glossary…………………………………………………………………10 Acknowledgements………………………………………………….......11 Introduction: This procedure manual will help properly train the staff on how to maintain a medical record. This includes medical office assistants, nursing homes, administrators and medical billing specialist. The reason for the manual is for medical/health record workers to develop and manage the records more effectively and efficiently. After reviewing the manual you should be able to: * Identify functions and purpose of a medical record * Understand multiple...
Words: 1147 - Pages: 5
...aspects always seem to be overlooked. On May 17, 2011, Ricardo Alonzo-Zaldivar wrote an article for azcentral.com relating to the vulnerability of electronic medical records and its effects on patient privacy. In this document I will be discussing the issue on patient privacy and confidentiality. I will be touching base on the population it affects, arguments used within this article that support electronic medical records, ethical and legal issues involved. Along with the issues I will be discussing the managerial responsibilities and proposed solutions that may help in maintaining patient privacy under regulation that are being proposed within this article. The issue on patient privacy is nothing new and out of the ordinary within the health care field. According to the American Medical Association’s (AMA) Council on Ethical and Judicial Affairs the main purpose of a healthcare professional’s ethical duty is to maintain patient confidentiality and to allow the patient to be able to make a truthful disclosure of their personal information to the physician placing their trust that the physician will protect the confidential nature of the information disclosed. Unfortunately, physicians cannot entirely control the access to electronic medical records. If patients distrust and have the anxiety that their medical records will not be private, they might tend to tell their doctors less, or even to the point they refuse to seek care. The issue on privacy does not affect a certain generation...
Words: 1061 - Pages: 5
...Fundamentals of Law for Health Informatics and Information Management Second Edition Check Your Understanding Chapter Answers CHAPTER 1 Check Your Understanding 1.1 1. A hybrid record is refers to record that is totally electronic. False 2. An electronic health record can be managed across more than one healthcare organization. True 3. Confidentiality refers to the right to be left alone. False 4. HITECH widens the scope of privacy and security protections under HIPAA. True 5. Privileged communication is a legal concept designed to protect the communication between two parties. True Check Your Understanding 1.2 1. Ownership of a health record generated by a doctor on a patient belongs to the patient. False 2. A custodian of records is responsible for certifying that a record is what it purports to be. True 3. When a patient refuses treatment he or she is exercising the ethical principle of beneficence. False 4. In a malpractice case, a professional code of ethics may be used as a benchmark for what should be acceptable practice by a healthcare professional. True 5. The ethical principle of nonmaleficence refers to making sure rules are fairly and consistently applied to all. False CHAPTER 2 Check Your Understanding 2.1 1. Private law defines rights and duties between individuals and the government. False 2. Statutes are enacted by legislative bodies. True 3. Administrative law is created by court...
Words: 6403 - Pages: 26
...Medical record keeping has change in the last couple of decades. In the past patients records were kept in a file on paper taking up excessive room. In the past, paper charts were the only means of keeping a patient’s medical diagnoses documented. Some of these charts are still used today in healthcare facilities, lately; there have been great advancements in the medical field involving the creation and maintenance of patient records. There are electronic medical record computer systems and internet-enabled doctor correspondence methods. All of this is to make the experience better for the patient and easier for the medical provider. In 2009, the 111th Congress allocated $19 billion of the American Recovery and Reinvestment Act, toward the creation of an electronic health record (EHR) for each person in the United States by 2014. The recent debate over EHRs has focused largely on the economic, logistical, and political consequences of implementing such a system; however, the country should also contemplate the ethical ramifications of EHRs. Addressing these concerns requires the application of ethical principles such as autonomy, justice, beneficence/non-maleficence, and privacy and confidentiality. The use of electronic technology for the management of health information presents expanded security risks due to increased capacity and mass storage. A single breach in security could lead to the unauthorized disclosure of private health information. Both health care organizations...
Words: 877 - Pages: 4
...ERMA: Electronic Record Management Application Stacey N. Tucker DeVry University Table of Contents Section Page Number Introduction 3 The Creation, Birth, and Development of ERMA 4 Legal Aspects 5 Strengths of Vizion 7 Weaknesses of Vizion 8 Strengths of ERMA 9 Weaknesses of ERMA 10 Recommendations for Improvement 11 Conclusion 12 Terminology 13 References 14 ERMA: Electronic Record Management Application ERMA, or the Electronic Record Management Application, was designed and developed by Correct Care Solutions for use in correctional facilities across the country. Used primarily in the ambulatory setting and clinics within correctional facilities. ERMA was primary created, and copyright protected for Correct Care Solutions in 2011 and since has been implemented in over two hundred correctional facilities. In 2013, the El Paso County Criminal Justice Center underwent a change of contract, this meant that their medical department was no longer ran by Correctional Health Care, and as such was no longer privy to their current electronic health record Vizion. The conversion from Vizion to ERMA would end up taking almost 2 full years to be put into full effect. The program implementation was meant with many challenges, these included both legalities and overall functionality. Compared to its predecessor ERMA is was still in its infancy and had a long way to go before it would...
Words: 3400 - Pages: 14
...practice efficient, standardized, electronic wound documentation and management, the solution can be discovered in health informatics software and digital wound imaging technology. The focus of health informatics is the patient and the process of care, and the goal is to enhance the quality and efficiency of care provided (Hebda & Czar, 2013). Category of Solution Rationale The rationale for the utilization of health informatics software and digital wound imaging technology is to decrease charting errors, staff frustration, and increase efficiency of wound documentation. It would also enhance workflow, cost-efficiency, and most importantly patient care. Fosco (2012) stated, "Facilities save on labor cost due to more efficient workflow, better clinician and staff time management, accelerated coordination of care, and automated processes” (Labor savings section, para. 1). Using a health informatics software and digital wound imaging technology together allows for an interoperable solution to manage health care information better. Regulatory, Legal, or Ethical Issues Regulatory, legal, and ethical recommendations are practiced in the health care setting to ensure safety, security, and reduce or eliminate the risk of injury or illness. When applying a new informatics and technology solution it is imperative that the policies and procedures of the health care organization are followed. The policies and procedures already in place normally meet the requirements of the...
Words: 676 - Pages: 3
...To choose an appropriate system, we should determine which system meets the needs of our practice as well as legal and regulatory requirements of our jurisdiction. We should also determine how the chosen system will work in concert with other electronic records systems. We must know the compatibility requirements as may be prescribed by the health authorities, health facilities or clinics. To facilitate this choice, there are various professional resources, including technology providers, consultants Information Technology, provincial, territorial or national medical associations and local technical support programs for doctors. Colleagues who have implemented an EHR system can also provide useful information. Some organizations of a province or territory have a list of pre-approved suppliers that facilitates the selection process and can also offer subsidies to offset part or all of the costs of acquisition and implementation. The system vendor will likely require that we sign a license to use the software, which is a legal agreement governing the use and distribution of EHR...
Words: 474 - Pages: 2
...The Health Information Technology for Economic and Clinical Health Act, better known as HITECH, is part of the American Recovery and Reinvestment Act of 2009. ARRA contains incentives related to health care information technology in general and The HIPAA Privacy Rule gives you rights over your own health information, regardless of its form. Whether your record is in paper or electronic form, you have the right to your records. HIPPA contains specific incentives designed to accelerate the adoption of HER systems among providers. The HIPPA act contains 5 different sections. Tite 1, the health insurance reform. Title I protect health insurance coverage for individuals who lose or change jobs. Title 2 is known as...
Words: 691 - Pages: 3
...Health Care Information System Terms Health Insurance Portability is known as HIPPA are rules that is made to improve effectiveness and the value of Healthcare system in America. HIPPA help with privacy of Patients Electronic Medical Records and Electronic Health Records this give patients confidences that their labs, Medication, and any conversation the patient have with the doctor with not be public knowledge past, present, or future information, even if its psychological or physical health or about the payment which I given to the medical doctor . All new staff must be trained the importance of patient privacy, implementation of proper security, risk assessment, data encryption, audit trails, and the use of firewall protection, and virus checking. Through the use of HIPPA guidelines the health care organization gave their patient greater protection. Facilities that obtain a NPI which replaced all passed patient Identification numbers, through clearinghouses, medical doctor. HIPPA rules of privacy require that medical facilities have written Notice of Privacy Practices this is a descripition of the document and its disclosure All doctors, nurses, physical therapist, pharmacists, home health agencies laboratories, nursing, chiropactors, dentist must apply HIPPA. Electronic Medical Records are digital version of paper Charts that utilized to keep patients information on the Computers, which allow a physician to access a patient ...
Words: 820 - Pages: 4
...Organizational Transition to Electronic Health Records Terry Badey- McClelland Capella University Omega Home Health Agency Omega Home Health Agency (OHHA) was established in 2010, to provide care services for disable and elderly adults in their homes in North Carolina. The organization is the second largest home health agency in the state of North Carolina. The agency is licensed by the North Carolina Division of Facility Services, as a home health care provider. Omega Home Health offer a variety of services, such as, in-home health care, mental health services, group homes, respite and adult day care. Our objective is to assist clients in maintaining their health, safety, as well as their well-being, which allows them to remain at home, through the professional and quality care provided by our agency. Our vision is to transform home health through innovative ideas and missions that embody a holistic environment for our clients. Omega Home Health Agency partners with Carolina’s Medical Center. Omega Home Health Agency’s employees are Physicians, clinicians, licensed Registered Nurses, Certified Nursing Assistants, Medical Technicians, Dieticians, Registered Health Information Administrators, Registered Health Information technicians, licensed Counselors, Qualified Professionals, and Behavioral Technicians. Omega Home Health operates seven facilities throughout North Carolina, with facilities in Statesville, Hickory, Charlotte, Huntersville, Mooresville, Lincolnton, and...
Words: 1419 - Pages: 6
...patients have in relation to potential security risks related to health care. Patient privacy and medical document security are the main topics of this article. The article discusses the importance of provider confidentiality, proper handling of health information along with proposed solutions for potential security issues. There is a focus on the patients perception of what is considered to be protected. Loria points out that forty-five percent of patients are apprehensive about security gaps involved with their private health information (Loria, G., 2015). Protected Health Information: Patient Privacy Concern The potential breach in HIPPA, Health Insurance Portability and Privacy Act of 1996, brings up several patient privacy concerns. One consideration is the method that the patient’s health data is distributed and utilized. Electronic health records are at risk of security breaches from hackers without adequate safety measure in place. According to Loria, (2015), “In January, health insurance provider Anthem discovered that hackers had broken into a database containing up to 80 million records. And just six months prior, Chinese cyber attackers stole personal information belonging to 4.5 million patients of hospital chain Community Health Systems.” There is not one demographic that is not affected when contemplating exposure of health care information. Potential breaches in access to medical records can affect anyone who seeks medical services. The...
Words: 1506 - Pages: 7
