Abbreviations: Necessary Or Destroying Medical Records?

There are two prohibited abbreviations that are tracked, “cc” and “qd”, as they are the most common. Throughout the year there has not been consistent improvement in the area. The trending data shows some improvement in parts of the year and then some months, April and September, to have increased spikes of use of prohibited abbreviations. During the PPR it was noted that the following departments were non-compliant concerning using prohibited abbreviations: 3E, 4E, ICU, and Telemetry. The

When confidential patient information is disclosed without consent it is a violation of the HIPAA Title II Security Rule. This rule was enacted in response to private information being leaked to the news and emails containing privileged information were read by unauthorized people. Identity theft is a real concern so patient privacy should be taken seriously. This is a rule can easily be broken without the

In the health care business, there are certain standards and laws that have been put in place to protect our patients and their personal health information. When a health care facility fails to protect their patient’s confidential information, the US Government may get involved and facilities may be forced to pay huge sums of money in fines, and risk damaging their reputation.

An outside business can dispose of protected health information by purging or destroying electronic media. This is covered in 45 CFR 164.308(b), 164.314(a), 164.502(e), and 164.504(e). HHS HIPAA Security Series 3: Security Standards – Physical Safeguards is a good source for more information. The Medical Records Director should maintain documentation with all

Abbreviations as part of the communication plan; currently Nightingale Community evaluates the non-approved abbreviations monthly and has made improvements during the accreditation audit period. Non

From an organizational level, plain language can be used as a strategy in hospitals or health system because when a health care provider is speaking to a patient, they should use words that are easy to understand. It is very easy and harmful to make medical mistakes when both parties cannot communicate on the same level. Replacing complex terms such as myocardial infarction to heart disease can help the patient understand the term more. Another example would be replacing the term “angina pectoris” to “chest pain.” Changing medical terms will

If formal communication is not used in the correct environment, misunderstanding may occur, causing danger to somebody’s health. Appropriate language must also be used; Professional references, proper English without slang and clear consistent wording.

HIPAA requires nurses and nursing students to keep patients’ medical records confidential at all time. For instance, I used computer to review patient’s diagnosis, I made sure that I signed off the computer after using it. I also made sure that all the information I brought home with me did not include patient’s name and other information that identify patient identity.

According to Iron Mountain (2015), failing to dispose of patient medical records securely is a HIPAA violation of unwilling negligence, which is another legal issue in scheduling patient appointments. When a patient declines an appointment or does not respond to requests to call the office to schedule the appointment, the medical records must be securely disposed of, or shredded. For example, when a referring PCP or specialist office calls and schedules an appointment, on behalf of the patient, during the initial phone call, the patient may not be aware of the referral. Furthermore, the patient may not be available on the date and time selected by the referring office. Consequently, when the patient contacts scheduling to inquire about

Complete the medical abbreviations chart. (Note that the medical abbreviations are the same as those highlighted in yellow in Jane Dare’s Health Record). In the second column, list what each of the individual letters in the abbreviation represents. In the third column define the context or meaning of the term that the abbreviation represents. Use simple terms. Finally, in the far right column, identify the source document. For example, face sheet, discharge summary, progress notes, or x-ray report.

Recycling is always a good habit but when someone uses your personal information and very sensitive information, it can becomes an issue. The 13 investigators team from WTHR in Indiana, found medical records in a dumpster. A dumpster that belonged to Olive Branch Christian Church.

A medical setting in which a patient feels safe and secure is more likely to create the conditions in which optimal outcomes can be achieved. Part of helping to ensure a patient feels secure is addressing the communication barriers between the provider and the patient. Some of these barriers arise from the use of professional jargon. Surgeons, Physicians, Nurses, etc. work at a fast pace to make sure that every patient is attended to. As this is their profession, medical jargon is used frequently when communicating to each other, figuring out a diagnosis, and coming up with a treatment plan for the patient. But this medical jargon creates a barrier between the healthcare professional and the patient. There can be misunderstandings between the patient and the professional when it comes to diagnoses and treatment plans due to the communication barrier. The professionals commonly use medical terminology to inform the patient of their status and a patient may simply nod their head to be polite. This nod does not necessarily mean that there is a mutual understanding, it could potentially mean that they are overwhelmed and don’t know how else to act in response to long confusing words being directed at them. This is dangerous because a patient could leave the facility not knowing how to appropriately take care of themselves after their procedure/diagnosis. Medical jargon has the potential to cause the patient and medical professional relationship to be both broken and

In the state and federal laws that I live in it is mandatory record retention are requirements apply to hospital or facilities rather than a physician practices. Hospital are to retain records up to five years and six years if critical. OSHA has required for employer to retain medical records for 30 years for employees who have been exposed to toxic substances and harmful agents. The HIPAA privacy law regulations requires that medical records are to be retained for six years from when the medical record was created, in which it follows the federal statute of limitations for civil penalties.

Do not discuss patients while you are in public areas. When medical records are not in use, they should be put away. Never remove the patient's official medical record from your office. You should not leave records out where your family members or others may see it. If any copies are made and not used they should be shredded.

I am all for electronic medical records. I have been in the healthcare field long enough to remember when patients medical records were paper. In my experience, paper medical records allow for patient privacy to be compromised. Some examples on how patient privacy can be disturbed when it comes to paper medical records are that almost anyone can go into the patient 's chart that is in the nurses station. This can include physical and occupational therapists, certified nursing assistants, nurses and physicians who are not caring for the patient. There have been times where I have walked to the nurses station at my job and it