Legal Health Record

US Congress created the Hipaa bill in 1996 because of public concern of how their private information was being used. It is the Health Insurance Portability and Accountability Act, which Congress created to protect confidentiality, privacy and security of patient information. It was also for health care documents to be passed electronically. Hipaa is a privacy rule, which gives patients control over their health information. Patients have to give permission any healthcare provider can disclose any information placed in the individual’s medical records. It helps limit protected health information (PHI) to minimize the chance of inappropriate disclosure. It establishes national-level standards that healthcare providers must comply with and strictly investigates compliance related issues while holding violators to civil or criminal penalties if they violate the privacy of a person’s PHI. Hipaa also has boundaries for using and disclosing health records by covered entities; a healthcare provider, health plan, and healthcare clearinghouse. It also supports the cause of disclosing PHI without a person’s consent for individual healthcare needs, public benefit and national interests. The portability part of Hipaa guarantees patients health insurance to employees after losing a job, making sure health insurance providers can’t discriminate against people because of health status or pre-existing condition, and keeps their files safe while being sent electronically. The Privacy

The health record is a collection of information about a patient’s past and present health. The primary purpose of the health record is to document the health history of the patient. It helps in patient care management and patient care support process. Moreover, record’s primary purpose is to get information for billing and reimbursement. The secondary purpose of the health record is to provide a legal record of care given and act as a source of data to support clinical audit, research, resource allocation, performance monitoring, epidemiology and service planning. Sometimes health information will be de-identified before it is used for these secondary

. HIPAA privacy rules are complicated and extensive, and set forth guidelines to be followed by health care providers and other covered entities such as insurance carriers and by consumers. HIPAA is very specific in its requirements regarding the release of information, but is not as specific when it comes to the manner in which training and policies are developed and delivered within the health care industry. This paper will discuss how HIPAA affects a patient's access to their medical records, how and under what circumstances personal health information can be released to other entities for purposes

Health information is an important source of information and evidence when the services provided are communicated in legal and professional documentation. It is a documentation which is a legal requirement and a record of the beneficiary’ care as well as a communication vehicle between other disciplines and providers. It not only ensures the services provided to individuals but is a crucial tool to support reimbursement of services and a basis for research. Incomplete and improper documentation potentially may lead into a denial of payment for services as well as question’s the quality of care provided.

According to both HIPPA and HITECH, an organization must have policies and procedures in place to enforce data storage integrity. This means the organization must take measure to protect healthcare information from an unauthorized user and there must be a way to successfully retrieve any and all patient information in the health information system. By doing so, the organization is ensuring integrity, inadvertent disclosure and availability of their records (Hawkins, 2013).

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

The Health Insurance Portability and Accountability Act (HIPAA) was passed by congress in 1996, and helps to ensure the privacy and security of Electronic Health Records (EHR's). By following the rules and regulations set forth under HIPAA, we can ensure the safety of patients' EHR's. We are responsible for protecting patients' records, and there are many measures we can take in order do this. Firstly, we must always keep patients' health information private. This means no discussing the records with people that are not authorized to know, and even then, we should only disclose the minimum necessary amount of information possible. For covered entities, we must designate a privacy and security officer to ensure the privacy

The Health Insurance Portability and Accountability Act also known as HIPAA was first signed into law on the federal level in 1996. Since it was signed into law it has had a huge effect on patient’s privacy, healthcare workers and even insurance company’s. “HIPAA is intended to improve efficiency throughout health care and requires that health care providers adhere to standardized national privacy and confidentiality protections.” (OMA p .236). It’s an invaluable tool that has created a standard of compliance across the healthcare field.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) affects every aspect of health care from patient privacy to insurance coverage. The federal act was first passed in 1996, yet the first major rule did not go into effect until 2003, protecting patient privacy. HIPAA ultimately came into effect due to the issues regarding patient privacy, security and coverage. Another major concern for both health care workers and the public was the exchange of patient information from one facility to another. Until the relatively recent decision to enforce HIPAA, a patient’s medical record was primarily recorded and maintained on paper and stored in locked cabinets or drawers. Not only was this method inefficient, but patients

In the modern world technology is everywhere and it affects everyone’s daily life. People are constantly attached to cell phones, laptops, and other electronics, which all have affected how people live their lives. Technology is also a large part of the healthcare system today. There are many electronics and technologies that are used in health care, such as electronic health record, medication bar code scanning, electronic documentation, telenursing, and there are many more forms of technology that impact nursing. One technology that stands out is the electronic health record. The electronic health record, also referred to as EHR, is an electronic version of a patient’s chart, and it contains is a list of the patient’s current medications, allergies, laboratory results, diagnoses, immunization dates, images, treatments, and medical history (“Learn EHR Basics,” 2014). The purpose of the electronic health record is to have a patient’s health care record available to health care providers nationwide, but the patient can decide who has access to their record (Edwards, Chiweda, Oyinka, McKay, & Wiles, 2011). The electronic health record is a very important technology in health care and it impacts nurses, nursing care, and has a significant impact on patient outcomes.

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.

The department of Health and Human Services protects and guides the health and well being of individuals here in America (Thacker, 2014). They fulfill these duties providing Americans with adequate and efficient health and human services and monitoring services designed to increase the efficiency of care in the health system (Thacker, 2014). One of the services being monitored by the department of Health and Human Services is the electronic health record system, which carries private and vital information of patient’s health record enabling all eligible participating health workers access to these records (Thacker, 2014). A breach of the protective health information of patients in a health organization creates chaos as these are against the health insurance portability and accountability (HIPAA) law (Thacker, 2014). Hence, measure will have to be put in place to determine what caused the breach and how to rectify it to ensure the breach never happens again (Thacker, 2014).

Documentation plays a vital role in research, education, quality assurance and reimbursements for both patients and providers (Okaisu, Kalikwani, Wanyana, & Coetzee, 2014, p. 1). The importance of documentation is not lost on any RN, but continuity in what is recorded and what is absolutely necessary to have in a patient’s record is not always met.

Healthcare organizations usually decide which data need to be stored electronically. The process of scanning documents follows some simple steps, which will guarantee the good results and avoid frustration. The very first step is for HIM professionals to develop an instruction set for the purpose of locating the information. The next steps are verifying the documents that are needed to be scanned and properly labeling the scanned documents before sending them to off-site storages. That process will eliminate confusion in storing and allow easily retrieve of records when needed. Once scanned, the documents should be sorted and stored under correct patients’ records with appropriate file names for indexing. After that, HIM professionals must

The importance of patient information system is related to different needs and objectives. They constitute the permanent documentation of patient health, permitting the medical professional to evaluate symptoms and signs within a broader temporal perspective, contributing to improvements in making diagnoses and providing treatment. The value of the patient record is also understood within the legal scope because it can be taken to trial, allowing doubts to be clarified and behaviors to be discerned, which, in turn, can protect patients, medical professionals, and other involved parties.