Hm300 week 5 part 1 of 2
- 1. © 2017 American Health Information Management Association© 2017 American Health Information Management Association Chapter 9: Legal Health Record: Maintenance, Content, Documentation, and Disposition Fundamentals of Law for Health Informatics and Information Management, Third Edition
- 2. © 2017 American Health Information Management Association Purposes of the Health Record • Patient care: Documentation patient treatment and continuity of care • Proof of services for reimbursement • Proof of quality and effectiveness of care (e.g., for accreditation, certification, licensure) • Support medical research • Support education and training • Support organization’s operational activities • Facilitate managerial decision-making to improve quality of patient care • A legal document/evidence in legal actions – Adage: “If it isn’t documented, it wasn’t done.”
- 3. © 2017 American Health Information Management Association Legal Health Record (LHR) • Business record that would be disclosed upon valid request • Content of LHR must be identified and managed by inventorying all source systems contributing to the record (e.g., paper and electronic documents, databases, images) • Organizations must determine what becomes part of the LHR, analyzing inclusion of items such as – E-mails – Videos – Metadata
- 4. © 2017 American Health Information Management Association Designated Record Set vs. LHR • Per HIPAA, a designated record set (DRS) is “used in whole or in part…to make decisions about individuals” and includes health records and records involved in billing, insurance enrollment and coverage • A DRS encompasses more information than what is usually considered part of the legal health record
- 5. © 2017 American Health Information Management Association LHR: Paper vs. Electronic Health Records • Six key differences: – Large volume and ease of duplication – Persistence: Electronic documents more likely to continue to exist – Metadata: Tracking data about data – Automatic updates – Obsolescence: With outdated programs or equipment – Searchable and dispersed in multiple locations; more likely with electronic records
- 6. © 2017 American Health Information Management Association LHR: Uniform Photographic Copies of Business and Public Records as Evidence Act (UPA) • Both federal and state versions exist • Supports the transition from paper to electronic storage of information • States that the reproduction of any record that has been retained in the regular course of business and kept by a process which accurately reproduces the original in any medium will be admissible as evidence
- 7. © 2017 American Health Information Management Association LHR: Maintenance, Content, Documentation and Disposition • Federal Laws – Medicare Conditions of Participation • State laws • Accreditation standards – Joint Commission – Other standard setting organizations • Professional guidelines—AHIMA • Facility policies—outlined in medical staff bylaws
- 8. © 2017 American Health Information Management Association LHR: Documentation Principles • Language: – Entries should be • Specific • Objective • Factual, not speculative or opinion (or should be documented as such) • Devoid of generalizations or vagueness (e.g., confused, anxious, appears to be…) – Response to care should be documented – Deviations from standard treatment (and patient response) must be documented completely – Situations that result in incident reports should be documented objectively • Blame or failure should not be documented in the record
- 9. © 2017 American Health Information Management Association LHR: Documentation Principles (continued) • Individuals who may document – Documentation in the record shall be completed only by those authorized per medical staff bylaws – Providers are responsible to provide high-quality and complete, authenticated documentation • Gaps and omissions – Detract from the chronology of care and increase likelihood of liability – Gaps: Spaces left between entries in the health record – Gaps and omissions in time refer to lengths of time when there is no documentation
- 10. © 2017 American Health Information Management Association LHR: Documentation Principles (continued) • Orders: – Written – Verbal (in-person and telephone) • Illegibility of orders is progressively being resolved through CPOE • Medical staff bylaws specify categories of personnel who may accept orders • All orders must be authenticated (verified) by the provider who gave the order or who is responsible for the patient’s care – Time requirements for authentication are governed by state law • Concurrent review of orders ensures timely authentication
- 11. © 2017 American Health Information Management Association LHR: Documentation Principles (continued) • Hostile patients – Require particular attention to objective documentation • Staff disagreements – Differing opinions must be documented in the record if pertinent to care – However, documentation should not highlight disagreements – Language must be objective and factual
- 12. © 2017 American Health Information Management Association LHR: Documentation Principles (continued) • Injuries resulting from criminal activity – Objective and factual documentation – Documentation should include statements made, identification and thorough description of of injuries, and photos • Liability for improper entries – Heightened is documentation is missing, incomplete, biased, critical, and based on opinions rather than fact
- 13. © 2017 American Health Information Management Association LHR: Legally Defensible Record • Data governance: Associated with data creation – Emphasis on accuracy and integrity • Information governance: Associated with information after it has been created – Emphasis on safeguarding and protection
- 14. © 2017 American Health Information Management Association LHR: Legally Defensible Record • Authentication and attestation – Authenticity: Genuineness of a record; that it is what it purports to be – Authentication: Security process that verifies one’s identity and authorizes system access – Attestation: Applying a signature to documentation, showing authorship • Paper records: Handwritten signatures; initials; rubber signature stamps (not favored) • Electronic records: Digitized signature; button, PIN, biometric identifier or token; digital signature (all referred to as electronic signatures)
- 15. © 2017 American Health Information Management Association LHR: Legally Defensible Record (continued) • Uniform Electronic Transactions Act (UETA): electronic records and signatures legally equivalent to paper records and handwritten signatures • Electronic Signatures in Global and National Commerce Act (E-SIGN): Validates electronic records and signatures, to be legally recognized for interstate and foreign commerce
- 16. © 2017 American Health Information Management Association LHR: Legally Defensible Record (continued) • Attestation issues: – Countersignatures – Multiple attestations – Attestation on behalf of another – Auto-attestation – Batch signing – Scribes
- 17. © 2017 American Health Information Management Association LHR: Legally Defensible Record (continued) • Integrity of electronic record content – Metadata: Provides background information about actions that affect creation, revision, and access to data – Documentation templates: Increase efficiency and structure, but create integrity issues
- 18. © 2017 American Health Information Management Association LHR: Legally Defensible Record (continued) • Accuracy: Degree to which information in the record reflects what actually happened • Authorship and Cut, Copy, Paste (Cloning): – Information may be placed on wrong encounter or wrong patient – Medical plagiarism: Using another’s documentation without permission – Risks of healthcare fraud when documentation from another provider or another patient’s record is used
- 19. © 2017 American Health Information Management Association LHR: Legally Defensible Record (continued) • Abbreviations: Must use only organization- approved abbreviations – Must not use Joint Commission prohibited abbreviations • Legibility
- 20. © 2017 American Health Information Management Association LHR: Legally Defensible Record (continued) – Changes to the health record: Only per organizational policy • Revisions: Replacing inaccurate information with accurate information after attestation • Additions: – Late entry: Entry missed or not written in timely manner – Amendment: Information added to support or clarify (HIPAA individual right) – Addendum: New documentation added to original entry after attestation
- 21. © 2017 American Health Information Management Association LHR: Legally Defensible Record (continued) • Changes to the health record: – Removal: • Deletion: Permanent elimination of information (limited, if permitted at all) • Retraction: Information no longer available for viewing but is available in the background – Version management: How an organization handles numerous iterations of a document • If used for patient care, must be retained
- 22. © 2017 American Health Information Management Association LHR: Legally Defensible Record (continued) • Timeliness and completeness: – Timeliness: Promptness of documentation – Completeness: Comprehensiveness of documentation – Mandated by accrediting and licensure bodies – Important from evidentiary standpoint
- 23. © 2017 American Health Information Management Association LHR: Legally Defensible Record (continued) • Printing – Problems: • Documents printed from EHR, with handwritten documentation on printouts (which one is the LHR?) • Duplicate copies lead to cumbersome records • Multiple copies heighten risk of privacy breaches • Printed version does not look like record viewed on computer screen, raising questions re: whether the two records are the same – Strict printing policies are important • Who has authority to print • Tracking printing in an audit tail • Format and version of documents that may be printed
- 24. © 2017 American Health Information Management Association LHR: Legally Defensible Record (continued) • Personal health records (PHRs) – Standalone PHRs – Tethered PHRs – Information provided by the patient – Question re: whether the PHR should be integrated into the LHR
- 25. © 2017 American Health Information Management Association LHR: Identification, Retention and Disposition • Health Record Identification – Master Patient Index (MPI) and Enterprise Master Patient Index (EMPI) • Patient matching • Health Record Retention – Storage and retrieval – Factors affecting retention periods: • Federal and state laws • Statutes of limitations • Accreditation standards • AHIMA recommendations (best practice) • Operational needs – Record retention schedules (paper record retention vs. electronic record retention)
- 26. © 2017 American Health Information Management Association LHR: Identification, Retention and Disposition • Health Record Disposition – Includes destruction or transfer to another medium or custodian – Must consider many of the same factors as those considered for retention periods – Destruction policy and procedure must consider: • Schedule for uniform destruction • Protection of information set for destruction (HIPAA) • Maintaining records scheduled for destruction that must be retained (eg, lawsuits, audits) • Method of destruction (shredding, burning, degaussing, etc.)
- 27. © 2017 American Health Information Management Association LHR: Identification, Retention, and Disposition • Health record disposition – Transfer policy and procedure must consider: • Moving from one medium to another (e.g., paper to document management system) • Moving records to another custodian – Ownership change – Departing providers – Closure of organization – Organization may be liable for failure to produce health record (paper or electronic) that should be available per policy and applicable laws