Delinquent Medical Record

Report all healthcare data elements required for external reporting purposes completely and accurately, in accordance with regulatory, and documentation standards.

Patients are also entitled to receive notice on how their health information is shared by health care covered entities, and are entitled to request a report once a year, free of charge, detailing who has received copies of their health information. Another aspect of the privacy rules provides patients with the right to choose who may receive health care information. Patients should be aware, however, that the provider does not have to agree to abide by their requests. Patients may determine whether or not their private health information may be shared with family members or others. Patients may also choose where they receive their health information. They could choose to receive their information via telephone, cell phone, e-mail, or any other reasonable means of contact. HIPAA also requires that covered entities provide their policies to patients that include information on how a patient might be able to file a complaint with either the covered entity or with the U.S. Department of Health and Human Services (U.S. Department of Health and Human Services, n.d.).

The primary goal of the Privacy Rule is to protect the individual’s health information from improper use and at the same time allowing the transfer of health information that will deliver and stimulate high quality health care. The Privacy Rule, affect health plans, health care clearinghouses, as well as health care provider who provide health information in electronic method in association with transactions for which the Secretary of HHS has adopted standards under HIPAA (HHS.gov, 2008).

Other patient information you may find is documentation for any allergies the patient may have. Insurance information will be noted if the patient is covered were you will find the provider, the billing address, and the patient’s policy number. There will be many different forms in this system that are used to document things such as the patient’s family history, diagnostic results, immunization records, past and present medications taken and the effectiveness of them, and of course there will be doctors notes for any office visits and hospitalizations. In the doctors notes and hospitalization notes you will find documentation for medical conditions or diseases the patient may have had in the past or has presently. Last but certainly not least there will be the common release and authorization forms, there may be advanced directives or living wills on file if the patient has completed them and other relevant information that staff and medical facilities may need to provide quality care for the patient. (Whatis.com, 2008).

Medical records should be organized in an orderly fashion, and all of the information within the record should be legible to the average reader. The information within the medical record must be accurate and corrections should be made and documented correctly. The wording in medical records should be easily understood and grammatically correct. All of these steps are important to remember when maintaining a medical record for future reference, or even legal issues. Discuss and explain the five basic filing

All healthcare providers, health organizations, and government health plans that use, store, maintain, or transmit patient health care information are required to comply with the privacy regulations of the HIPAA

In a general medical record a patient is entitled to a copy of his or her record, the only thing they would have to do

Inspect and manage medical records to insure that the correct information is being used for the right patient.

You are letting the provider know what the patient chief complaint or reasoning is to be seen at the office that day. All information the patient has prior will be beneficial for the process of the claim.

Healthcare organizations have been tasked to explicitly define organizational requirements for what their facility maintains as a legal health record and maintains as a designated record set. The requirement that healthcare facilities maintain a designated record set, in addition to a legal health record, is a HIPAA privacy rule (AHIMA, 2011). While all healthcare organizations will uniquely define both record sets, in order to be in compliance with HIPAA their definitions must contain common principles (AHIMA, 2011).

What provisions apply? When patients go to the Emergency Room, the patient registration staff always comes in and makes sure all patient demographics are correct along with the insurance information. After, everything is verified the patient signs a HIPAA privacy authorization form, which you decide if you want to disclose your personal records. When I sign I usually initial 3 parts of the form and sign at the bottom. I think it is great that we sign every time, because it protects you, and no body wants their medical records disclosed to the general public.

In addition to the core elements, providers will have to choose any five of the ten additional tasks to implement in 2011-2012. Some examples of these might be clinical lab results, patient appointment reminders and drug-formulary checks. This gives the providers a chance to choose their own path toward full EHR implementation and meaningful use. Legislation ties payments to the achievement of advances in health care processes and outcomes. The regulations are specific as to when providers will have to use particular functions in order to be considered meaningful users. The meaningful use rule acknowledges the urgency of adopting the electronic health record and recognizes the challenges it will pose on all providers.

Each policy that has been formulated and brought forth to legislation goes through its many challenges and analyzation before being implemented and becomes a policy and part of legislation. The statutes of HIPAA were brought forth and formulated in hopes of regulating covered entities and providing a type of universal protection of patient information and data. There is no doubt that the policy for HIPAA created skepticism about health privacy laws and the impact that it would have on the health care industry and its professionals.

Individuals should be able to see and get copies of their medical records and make corrections if they find mistakes.

3.) Under HIPAA, covered entities (healthcare providers, health plans and healthcare clearinghouse) must comply with the privacy rules. A covered entity may develop its own privacy rules that would accommodate its own needs of protected health information (PHI) management but it most comply with the HIPAA guidelines. It is the responsibility of the entity to put in place a privacy official to oversee the policies, procedures and be on hand and available to be contacted in reference to the privacy rule. A patient should be given a privacy notice act at his/her health facility stating how their (PHI) is being used and to whom it will be shared. The covered entity should include in the notice their duty to assure the patients privacy as well as how and whom to contact if there is a complaint or they feel that their rights have been violated. As of 2009 the Office of Civil Rights (OCR) handles complaints that are made on privacy policies, procedure and practices of HIPAA covered entities.