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HIPAA Compliance and Record 
Handling 
Zachary Sharp 
MHA 690 
Doctor David Cole 
September 30th, 2014
UCLA Prominent Patients 
Medical Record Handling 
UCLA Hospital 
Mission Statement: 
To provide excellent 
patient care 
in support of the 
educational and 
scientific programs of 
the schools of the UCLA 
Center for the Health 
Sciences 
(UCLA Health System, 2011). 
Compliance Call to Action 
Issues to be discussed 
1. HIPAA Fines 
2. Zero Tolerance 
3. “ Oath to do no 
Harm” 
4. “Standard of Care” 
5. Quality standard 
6. Patient Privacy 
7. Patient 
Confidentiality
UCLA Prominent Patients 
Medical Record Handling 
HIPAA Law-Fines 
• HIPAA Security: Harsh 
Fines, Penalties Are a 
Wake-up Call to Us All 
• $1-million fine 
• Corrective action plan 
• Unauthorized patient file 
access = violation of the 
HIPAA Privacy Rule 
• Requirements to develop 
comprehensive policies and 
procedures 
• Cause and Effect 
HIPAA compliance- “Mandatory” 100%
UCLA Prominent Patients 
Medical Record Handling 
Zero Tolerance 
for Non-Compliancy to HIPAA Rules and 
Regulations. 
Termination for Repeat Offenders 
(Case by Case Basis)
UCLA Prominent Patients 
Medical Record Handling 
Standard of Care 
“Oath to do no harm- non-malfeasance” 
 The Standard of Care is a case- and time-specific analytical 
process in medical decision-making, reflecting a 
 clinical benchmark of acceptable quality medical care. This 
benchmark, which is used to evaluate and guide the practice 
 of medicine, encompasses the learning, skill and clinical 
judgment ordinarily possessed and used by prudent health 
care 
 providers or payers of good standing in similar circumstances. 
The standard of care must reflect the art (consensus of 
 opinion of clinical judgment) and science (published peer 
reviewed literature) of medicine and must be uniform for all
UCLA Prominent Patients 
Medical Record Handling 
Standard of Care Continued 
“Oath to do no harm- non-malfeasance” 
 health care personnel whether they are providing direct 
clinical care or reviewing the medical necessity of past, 
present or 
 future medical care. A violation of standard of care may 
result in under-utilization of medical care, but also occurs 
when 
 unnecessary care (over-utilization) is provided. The 
standard of care has a national and clinical basis, rather 
than a local 
provider community or payer review basis. 
ACMQ.org. (2010).
UCLA Prominent Patients 
Medical Record Handling 
• Quality Standards are 
paramount to the 
Hospital’s Success 
• Patient Privacy 
• Patient Confidentiality 
Effective Immediately 
Training 
 Mandatory 6 months 
training for all employees 
on HIPAA Guidelines 
 All media 
inquiries/questions 
should be directed to our 
public service experts
UCLA Prominent Patients 
Medical Record Handling 
Media Handling 
Any questions in regards to celebrity patients 
should only be handled by trained individuals 
in healthcare public relations departments 
authorized by hospital.
UCLA Prominent Patients 
Medical Record Handling 
Effective Immediately 
 Restricted Access 
 Celebrity patient medical 
records will be placed in 
special secured files 
which have to be 
accessed by medical 
record director or other 
designated persons. 
 This method helps to 
alleviate unauthorized 
access of prominent 
patient records.
UCLA Prominent Patients 
Medical Record Handling 
Procedures for Supervisors/Medical Records Administration 
Handling 
• All information released should be approved and released 
after being verified to be accurate and consistent. Only 
what patient has authorized after review board approves. 
• Steps to prevent unauthorized usage and disclosure of 
medical information: 
• Replacing patient’s name with an alias or coding system 
while in the hospital to be placed on bed boards, bulletin 
boards and patient room signs. 
• Restricted Access and alert system of unauthorized breach 
based on clearance level.
UCLA Prominent Patients 
Medical Record Handling 
Procedures for Supervisors/ 
Medical Records Administration Handling Continued 
• Paper Based Records- Assign head nurse as designated 
person per shift to access records. 
• All employees will undergo nondisclosure training and 
sign nondisclosure form. 
• Discharge- Restrict access to persons only required to 
close out file and follow- up care documentation only. 
• Medical Records and the Law
UCLA Prominent Patients 
Medical Record Handling 
References 
UCLA Health System. (2011). About Ronald Reagan UCLA 
Medical Center. Retrieved from 
http://www.uclahealth.org/body_med.cfm?id=346 
NYU Langone Medical Center. (2011).HIPAA Security: Harsh 
Fines, Penalties Are a Wake up Call to Us All. Retrieved from 
http://compliance.med.nyu.edu/news/documenting-inpatient- 
admissions 
ACMQ.org. (2010). Standard of Care. Retrieved from 
http://www.acmq.org/policies/policies3and4.pdf

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Mha690 week 1 db 2

  • 1. HIPAA Compliance and Record Handling Zachary Sharp MHA 690 Doctor David Cole September 30th, 2014
  • 2. UCLA Prominent Patients Medical Record Handling UCLA Hospital Mission Statement: To provide excellent patient care in support of the educational and scientific programs of the schools of the UCLA Center for the Health Sciences (UCLA Health System, 2011). Compliance Call to Action Issues to be discussed 1. HIPAA Fines 2. Zero Tolerance 3. “ Oath to do no Harm” 4. “Standard of Care” 5. Quality standard 6. Patient Privacy 7. Patient Confidentiality
  • 3. UCLA Prominent Patients Medical Record Handling HIPAA Law-Fines • HIPAA Security: Harsh Fines, Penalties Are a Wake-up Call to Us All • $1-million fine • Corrective action plan • Unauthorized patient file access = violation of the HIPAA Privacy Rule • Requirements to develop comprehensive policies and procedures • Cause and Effect HIPAA compliance- “Mandatory” 100%
  • 4. UCLA Prominent Patients Medical Record Handling Zero Tolerance for Non-Compliancy to HIPAA Rules and Regulations. Termination for Repeat Offenders (Case by Case Basis)
  • 5. UCLA Prominent Patients Medical Record Handling Standard of Care “Oath to do no harm- non-malfeasance”  The Standard of Care is a case- and time-specific analytical process in medical decision-making, reflecting a  clinical benchmark of acceptable quality medical care. This benchmark, which is used to evaluate and guide the practice  of medicine, encompasses the learning, skill and clinical judgment ordinarily possessed and used by prudent health care  providers or payers of good standing in similar circumstances. The standard of care must reflect the art (consensus of  opinion of clinical judgment) and science (published peer reviewed literature) of medicine and must be uniform for all
  • 6. UCLA Prominent Patients Medical Record Handling Standard of Care Continued “Oath to do no harm- non-malfeasance”  health care personnel whether they are providing direct clinical care or reviewing the medical necessity of past, present or  future medical care. A violation of standard of care may result in under-utilization of medical care, but also occurs when  unnecessary care (over-utilization) is provided. The standard of care has a national and clinical basis, rather than a local provider community or payer review basis. ACMQ.org. (2010).
  • 7. UCLA Prominent Patients Medical Record Handling • Quality Standards are paramount to the Hospital’s Success • Patient Privacy • Patient Confidentiality Effective Immediately Training  Mandatory 6 months training for all employees on HIPAA Guidelines  All media inquiries/questions should be directed to our public service experts
  • 8. UCLA Prominent Patients Medical Record Handling Media Handling Any questions in regards to celebrity patients should only be handled by trained individuals in healthcare public relations departments authorized by hospital.
  • 9. UCLA Prominent Patients Medical Record Handling Effective Immediately  Restricted Access  Celebrity patient medical records will be placed in special secured files which have to be accessed by medical record director or other designated persons.  This method helps to alleviate unauthorized access of prominent patient records.
  • 10. UCLA Prominent Patients Medical Record Handling Procedures for Supervisors/Medical Records Administration Handling • All information released should be approved and released after being verified to be accurate and consistent. Only what patient has authorized after review board approves. • Steps to prevent unauthorized usage and disclosure of medical information: • Replacing patient’s name with an alias or coding system while in the hospital to be placed on bed boards, bulletin boards and patient room signs. • Restricted Access and alert system of unauthorized breach based on clearance level.
  • 11. UCLA Prominent Patients Medical Record Handling Procedures for Supervisors/ Medical Records Administration Handling Continued • Paper Based Records- Assign head nurse as designated person per shift to access records. • All employees will undergo nondisclosure training and sign nondisclosure form. • Discharge- Restrict access to persons only required to close out file and follow- up care documentation only. • Medical Records and the Law
  • 12. UCLA Prominent Patients Medical Record Handling References UCLA Health System. (2011). About Ronald Reagan UCLA Medical Center. Retrieved from http://www.uclahealth.org/body_med.cfm?id=346 NYU Langone Medical Center. (2011).HIPAA Security: Harsh Fines, Penalties Are a Wake up Call to Us All. Retrieved from http://compliance.med.nyu.edu/news/documenting-inpatient- admissions ACMQ.org. (2010). Standard of Care. Retrieved from http://www.acmq.org/policies/policies3and4.pdf