Question

Susie is a healthcare manager at a local doctor’s office. One day, the doctor asks Susie to pull a patient’s medical record and make updates to the file. After the updates are complete, Susie needs to properly store the file. In order for Susie to be successful and compliant, she must know how to properly maintain the patient’s medical record.

1, What are some of the important processes and concepts that Susie must know regarding the maintenance of a medical record?

2, Provide an example of an improper process or violation when maintaining medical records.

3, In your future career, how will you ensure proper maintenance of medical records and adherence to all medical laws?

Answer 1

1, What are some of the important processes and concepts that Susie must know regarding the maintenance of a medical record?

A medical record documents a Members medical treatment, past and current health status, and treatment plans for future health care and is an integral component in the delivery of quality health care. As such, we established medical record standards in 1996 and routinely distribute these standards to PCPs and specialists.

important processes

• A different issue list in every therapeutic record reports huge ailments and restorative conditions.
• A present medicine list.
• Medicine hypersensitivities and unfriendly responses are conspicuously shown in the record. On the off chance that the patient has no known hypersensitivities or history of unfavorable responses, this is properly noted in the record.
• Past medicinal history (for patients seen at least multiple times) is effectively recognized and incorporates genuine mishaps, tasks, and ailments. For kids and teenagers (18 years and more youthful), past restorative history identifies with pre-birth care, birth, activities, and youth ailments.
• For patients 12 years and over, there are suitable documentations concerning utilization of cigarettes, liquor, and substance misuse (for patients seen at least multiple times).
• The history and physical archives fitting emotional and target data for exhibiting grumblings.
• Working analyses are predictable with discoveries.
• Treatment designs are steady with determinations.
• Clinical assessment and discoveries are reported for each visit.
• Uncertain issues from past office visits are tended to in consequent visits.
• Audit for suitable usage of experts.
• There is no proof that the patient is set at improper hazard by an indicative or helpful technique. An inoculation record for kids is forward or a suitable history is made in the restorative record for grown-ups.
• An inoculation record for youngsters is state-of-the-art or a proper history is made in the therapeutic record for grown-ups.

MAINTENANCE OF RECORDS

Providers must maintain all medical and other records in accordance with the terms of their Professional Provider Agreement with AmeriHealth HMO, Inc. and the Provider Manual. Subject to applicable state or federal confidentiality or privacy laws, AmeriHealth or its assigned agents, and assigned delegates of neighborhood, state, and government administrative offices having locale over AmeriHealth, will approach supplier records, on demand, at the suppliers place of business amid typical business hours, to investigate and audit and make duplicates of such records at no expense to the Plan. At the point when asked for by AmeriHealth or its assigned agents, or assigned delegates of neighborhood, state, or government administrative offices, the supplier will create duplicates of any such records and will allow access to the first therapeutic records for correlation purposes inside the asked for time periods and, whenever asked for, will submit to examination under promise with respect to the equivalent.

2, Provide an example of an improper process or violation when maintaining medical records.

Everyone's medical situation is different; however, this article strives to help define HIPAA by providing you with an overview of some common HIPAA violations experienced by health care providers and patients.  

• Inability to hold fast to the approval termination date - Patients can set a date when their approval lapses. An infringement would discharge private records after that date.
• Inability to expeditiously discharge data to patients - According to HIPAA, a patient has the privilege to get electronic duplicates of medicinal records on interest.
• Inappropriate transfer of patient records - Shredding is essential before discarding patient's record.
• Insider snooping - This alludes to relatives or collaborators investigating a man's restorative records without approval. This can be stayed away from with secret phrase security, following frameworks and leeway levels.
• Missing patient mark - Any HIPAA shapes without the patient's mark is invalid, so discharging data would be an infringement.
• Discharging data to an undesignated party - Only the correct individual recorded on the approval frame may get understanding data.
• Discharging unapproved wellbeing data - This alludes to discharging the wrong record that has not been affirmed for discharge. A patient has the privilege to discharge just parts of their restorative record.
• Releasing wrong patient's information - Through a careless mistake, someone releases information to the wrong patient. This sometimes happens when two patients have the same or similar name.
• Right to revoke clause - Any forms a patient signs need to have a Right to Revoke clause or the form is invalid. Therefore, any information released to a third party would be in violation of HIPAA regulations.

3, In your future career, how will you ensure proper maintenance of medical records and adherence to all medical laws?

This guideline describes the basic steps you must take to comply with the Privacy Rule. However, you or whoever is in charge of the Privacy Rule should learn more about state and federal privacy law. The two links at the end of this guideline have several documents you can download, at no charge, to clarify and explain in greater detail, every aspect of the law.

• Placed somebody in control.
• Keep Protected Health Information (PHI) secure and private.
• Set up office approach, usage systems and preparing for your staff.
• Advise patients of their rights and bolster those rights.
• Limit access of patient data to organizations outside the training.