Freestanding Ambulatory Care. An Ambulatory Care Facility

A patient has just left the office after having an outpatient surgery procedure. As you get ready to put away the patient’s file, you realize that the patient has forgotten to take his prescriptions and after-care instruction sheets home with him. It is vital for proper healing and recovery for the patient to have these documents. You know you will have to contact this patient so you look inside for his contact information and signed HIPAA Release of Information form.

primary and secondary health care facility providing an array of patient care services in the areas

Record keeping provides evidence of any interaction or intervention involving a patient. It needs to be comprehensive enough to determine that the nurse has fulfilled his/her legal and professional duty of care (Griffith 2007).

Long term care facilities are first established under state licensing laws and, in most cases, a granted certification that there is a need for nursing home beds in a specific community. Medical professionals and support services providing care and related functions must also operate in the nursing home under the licensing, regulatory, and standards of practice governing their areas of specialty. In addition, each long-term care facility must establish their own policies and procedures for everyday operation to stay within their operating standards and legal limitations (Brady,

There should not be any information held which is not relevant to the resident or their care. A resident's record should never be kept longer than necessary.

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

There are 9 types of health care facilities that are accredited by the Joint Commission. The Ambulatory Health Care accreditation, encompassing organizations and facilities that provide outpatient services of medical/dental nature as well as diagnostic, surgical, and therapeutic services. Other types of facilities that are accredited are critical access hospitals, hospitals, laboratories, office-based surgical centers, and nursing care centers. There is also Home Care services, the Opioid Treatment Program, and the Behavioral Health Care Program. Critical Access Hospitals meet special requirements regarding patient beds and LOS. Hospitals that are accredited include general and specialty hospitals.

Any information utilized in, “documenting healthcare or health status,” of a patient must be included in the designated record set (AHIMA, 2011). This includes patient documentation collected on any medium, such as WAVE files or x-ray images (AHIMA, 2011). Consequently, due to the incorporation of clinical, administrative, and other protected private health information, the designated record set is extremely different from the legal health record (AHIMA,

9. What measures in terms of physical storage are taken to ensure the privacy of the medical record?

According to L. Horton, LTACHs are funded by commercial insurance, Medicare, and charity (personal communication, March 7, 2014). For claims reimbursed by Medicare, patient satisfaction survey’s or Hospital Consumer Assessment of Healthcare Providers and Systems/HCAHPS help determine the hospital’s reimbursement scores. Value Based Purchasing (VBP) was established by the Affordable Care Act, which implements a pay-for-performance approach to the Medicare payment system (“Linking Quality to Payment,” n.d.). This program can help hospitals evaluate the performance of the services they provide to the public. Part of the VBP plan includes a questionnaire to patients that determines 30% of the weight of the hospital’s reimbursement scores. There are eight measures included in the HCAPS: nursing communication, doctor communication, responsiveness of staff, pain management, communication of medications, discharge information, cleanliness and quietness of hospital environment, and overall rating (Grellner, 2012, p.57).

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.

the construction, development, or other establishment of a new hospitals, including general, acute-care and specialty hospitals

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

The purpose of this paper is to identify the type of facility and the resident being served. In addition, this paper will identify the role of the Nurse Practitioner (NP), and the regulatory issues as it supports this role.

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.