Scaler Case Study

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.

Unfortunately, I was not timely notified about the incident. Ms Louise received a call from Christian, OR RN in the room. Louise directed her to give me call, and even gave my number to her. Christian claimed that you already gave a go signal to do IUSS for the entire tray; and the entire tray is already being flushed sterilized at that time. This is a major deviation on sterile processing directive #1116. I wish I could have help find alternative actions, than flushing the entire tray –

When the referring PCP or specialist office faxes the patient’s medical records, one patient’s paper medical records can unintentionally become attached to another patient’s medical records, which is an example of a HIPAA violation of unwilling negligence (Iron Mountain, 2015). This can occur when several patients are referred to a specialist at the same time, and medical records for all patients are received through one fax transmission, requiring careful examination and separation of health records. To prevent paper medical records of one patient inadvertently becoming attached to the medical records of another patient when received by fax, all pages of the health record must be reviewed upon receipt and checked for the patient’s identification and consecutive numbering and

Unfortunately, with five medication aides and two managers all doing filing, records often get misplaced, whether they are put in the wrong section of the expand-a-file, filed under the wrong section of a resident’s binder or accidently get deposited into the secure shredding container. The implementation of a new health documentation system would be a marked improvement to the current system.

In the case listed here Dr. Loren J. Borud was scheduled to perform surgery on Mr. Michael Hicks early on a Friday morning. The surgery was liposuction and a scar repair procedure. Dr. Loren informed the patient the procedure would take approximately ninety minutes, but

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

When the referring PCP or specialist office faxes the patient’s medical records, one patient’s paper medical records can unintentionally become attached to another patient’s medical records, which is an example of a HIPAA violation of unwilling negligence (Iron Mountain, 2015). This can occur when several patients are referred to a specialist at the same time, and medical records for all patients are received through one fax transmission, requiring careful examination and separation of health records. To prevent paper medical records of one patient inadvertently becoming attached to the medical records of another patient when received by fax, all pages of the health record must be reviewed upon receipt and checked for the patient’s identification

2. In this case, how would you be able to correct your error and provide the missing documents to the patient while still protecting patient confidentiality under HIPAA?

Pretend you supervise the correspondence unit of the health information services department of a medical center. Today, you received a subpoena duces tectum from an attorney, demanding either the originals or copies of all health records concerning Mary Smith, who allegedly is or was a patient of the medical center. The subpoena lacks sufficient information for you to determine whether Mary Smith is or was a patient in your facility. The subpoena is not accompanied by a valid authorization to release information for Mary Smith, as required in your state. (Case Study, p. 62)

3- keeping the medical records in a cardboard boxes in overheated storage area could be damaged from fire or any other issue so easily so they have to keep the medical records in Flash drive or CD and keep another copy in the work computer.

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.

•Gloves must be worn when hand contact with blood, mucous membranes, OPIM, or non-intact skin is anticipated, or when handling contaminated items or surfaces, 29 CFR 1910.1030(d)(3)(ix).

During my clinical rotation in the ER, I had a patient who came in complaining with shortness of breath and cough for the past few days. He had a history of CHF and COPD and was on 2L of oxygen at night. While I assessed him with the nurse by my side, I heard audible wheezes and crackles in his lung bases. He also had a persistent cough. I knew that he was having a COPD exacerbation and needed appropriate medications to ease his discomfort. I discussed my findings with the nurse and after examining the patient the nurse agreed with me. We relayed the information to the physician who concurred with us after examination and gave us orders to treat the patient’s COPD exacerbation.

Records management is defined as the systematic life-cycle management of records that includes identification, collection, classification, storage, retrieval, and, eventually, disposition (Records Managment: Buisness Definition, 2010). There are many elements which fall under the management of patient records including but not limiting to; patient data maintenance, identifying, classifying, and storing records, and identifying information requiring capture. Questions six thru twelve of the interview assignment from week four discuss similarities and differences between the circulation, tracking and security measures for

I am pleased to say that these medical records are all in the three medical buildings that the staff transports them. There are no medical records that are missing as in thrown in the garbage or found in the street somewhere. Medical staff is giving an iPad with a new system called MediSystem that keeps track of out medical records. The physican is able to sign on the ipad. The system reminds the physician that they have up to two days to give back the medical records. They are able to have the medical records a day before a patient’s visit and the day of the patient’s visit. There is two staff that works the morning and night shift. One staff is responsible for collecting the medial records to put back and one staff is responsible to transport the medical records to the physician. When the staffs are on break physicians cannot request record through Medisystem until staff is back on break.